Quotes from Sidney Dekker

Underneath every simple, obvious story about 'human error,' there is a deeper, more complex story about the organization.

Accidents are no longer accidents at all. They are failures of risk management.

Not being able to find a cause is profoundly distressing; it creates anxiety because it implies a loss of control. The desire to find a cause is driven by fear.

If professionals consider one thing "unjust," it is often this: Split-second operational decisions that get evaluated, turned over, examined, picked apart, and analyzed for months—by people who were not there when the decision was taken, and whose daily work does not even involve such decisions.

There is almost no human action or decision that cannot be made to look flawed and less sensible in the misleading light of hindsight.

If we adjudicate an operator's understanding of an unfolding situation against our own truth, which includes knowledge of hindsight, we may learn little of value about why people saw what they did, and why taking or not taking action made sense to them.

There is almost no human action or decision that cannot be made to look flawed and less sensible in the misleading light of hindsight. It is essential that the critic should keep himself constantly aware of that fact."1

Accountability can mean letting people tell their account, their story.

Unjust responses to failure are almost never the result of bad performance. They are the result of bad relationships.

People do not come to work to do a bad job. Safety in complex systems is not a result of getting rid of people, of reducing their degrees of freedom. Safety in complex systems is created by people through practice—at all levels of an organization.

Arriving at the edge of chaos is a logical endpoint for drift. At the edge of chaos, systems have tuned themselves to the point of maximum capability.

Asking what is the cause, is just as bizarre as asking what is the cause of not having an accident. Accidents have their basis in the real complexity of the system, not their apparent simplicity.

In shipping, for example, injury counts were halved over a recent decade, but the number of shipping accidents tripled

Studying and enhancing the "information environment" for decision-making, as Rasmussen and Svedung put it, can be a good place to start.46 This information environment, after all, is where assessments are made, decisions are shaped, in which local rationality is created. It is the place where the social and the technical meet; where risk itself is constructed.

forward-looking accountability."2 Accountability that is backward-looking (often the kind in trials or lawsuits) tries to find a scapegoat, to blame and shame an individual for messing up. But accountability is about looking ahead. Not only should accountability acknowledge the mistake and the harm resulting from it, it should lay out the opportunities (and responsibilities!) for making changes so that the probability of such harm happening again goes down.

It has to do with being open, with a willingness to share information about safety problems without the fear of being nailed for them.

But the point of a 'human error' investigation is to understand why people's assessments and actions made sense at the time, given their context, and without knowledge of outcome, not to point out what they should have done instead.

This is at the heart of the professional pilot's eternal conflict," writes Wilkinson in a comment to the November Oscar case. "Into one ear the airlines lecture, "Never break regulations. Never take a chance. Never ignore written procedures. Never compromise safety." Yet in the other they whisper, "Don't cost us time. Don't waste our money. Get your passengers to their destination—don't find reasons why you can't.

Safety improvements come from organizations monitoring and understanding the gap between proceedures and practice

No matter how significant the numbers are according to their own logic, statistics fail to convey the true, lived meaning of the suffering they contain and can thus leave us numbly indifferent.

Tomorrow's accident, which will be rare but no doubt even more disastrous, will be an accident where the regulations were in place to prevent the problem, or perhaps where no-one actually made an identifiable error and no system truly broke down but all the components had been weakened by erosion: the degree of variation within the operating conditions will one day prove enough to exceed the tolerable linkage thresholds.

Oh, and what about the nurse? She was fired and charged as a criminal. That's Newton, too. If there are really bad effects, there must have been really bad causes. A dead patient means a really bad nurse. Much worse than if the patient had survived. So much worse, she's got to be a criminal. Must be. We can't escape Newton even in our thinking about one of the most difficult areas of safety: accountability for the consequences of failure.

There is almost no human action or decision that cannot be made to look flawed and less sensible in the misleading light of hindsight. It is essential that the critic should keep himself constantly aware of that fact.

Challenges to existing views are generally uncomfortable. Indeed, for most people and organizations, coming face to face with a mismatch between what they believed and what they have just experienced is difficult. These people and organizations will do anything to reduce the nature of the surprise.