Author: Sidney Dekker
Sidney Dekker hit the scene in a big way over the past few years, offering may great insights about human error and learning from errors that do occur within a just culture.
In this book, Dekker takes us far from traditional “Monday Morning Quarterbacking” and the old initial reaction of “Who are we going to hold accountable?!” when something goes wrong.
One of my favorite points of this book is that in order to truly understand why an individual made a specific choice that led to an error, you must (to the best of your ability) put yourself in the worker’s shoes, at that time, and under the same conditions in order to truly learn. Only by doing this can you uncover the landmines (setups, e.g., unclear procedure step, poor labeling, etc.), traps (conditions of the work environment that make human error more likely, e.g., time pressure, distractions, etc.), and psychological triggers that prompted the choice to take the action that was taken.
The book, as it’s name implies, is written for the practitioner, offering tangible steps and tools for learning post error. Anyone who is involved in safety and/or human error reduction, whether on the performance improvement side or post error/accident investigation side, should read and digest the material in this book. It should be a readily accessible reference on your desk or bookshelf.