A keynote address from Velocity Europe 2014 in Barcelona.

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When things go wrong in organizations, one thing is almost always found in the post-mortem: ‘human error’. No situation is too complex to be reduced to this simple, pernicious notion. ‘Human error’ has become a shapeshifting persona that can morph into an explanation of almost any unwanted event. With its various guises – ‘misjudgment’, ‘lapse of concentration’, ‘carelessness’ – it seeps into headlines and news reports. Twitter outage or train crash, the human is the culprit, error the cause.

But one only needs to look a little more deeply at the nature of system failures to see that things are not so straightforward. What seems to make sense as a causal catch-all for our everyday slips and blunders in life snaps when stretched; it fails to capture the context and complexity of our work and systems, and fails to help improve how things work. If the ‘human error’ explanation does not serve safety and business continuity, what does it serve? Perhaps it serves society’s need for simple explanations and someone to blame, while absolving it for its demands.

There is a better way, but it means that we have to refuse to oversimplify. Life after ‘human error’ means taking a road to recovery that takes a more nuanced and considered view of the person, system conditions, system behaviour and system outcomes. The good news is that the road is paved with concepts that help explain success as well as failure. A blend of humanistic thinking and systems thinking can improve both performance and wellbeing. This keynote will take a journey through the steps of recovery, from explaining away events to understanding how your system really works.

About Steven Shorrock (EUROCONTROL):
EUROCONTROL
Steve is a systems ergonomist and work psychologist with a background in practice and research in safety-critical industries. Steve is Project Leader, Safety Development at EUROCONTROL and the European Safety Culture Programme Leader. He is also Adjunct Senior Lecturer at the University of New South Wales, School of Aviation.

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