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Shifting the Focus from Human Error to Systemic Safety: A Path to Resilience

Posted by Robert O'Neill on Mar 29, 2023 3:59:00 PM
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Screen Shot 2023-03-21 at 3.28.33 pmIn high-stakes industries where safety is paramount, accidents and incidents are often quickly attributed to human error. This knee-jerk reaction to blame individuals has deep roots in organisational culture and leadership attitudes. However, this blame-oriented approach can hinder the development of truly resilient and safe systems. In this article, we will explore the limitations of focusing solely on human error, the benefits of adopting a systemic approach to safety, and how organisations can change their mindset to create robust, resilient systems.

Table of Contents

  1. The Problem with Blaming Human Error
  2. The Systemic Approach to Safety
  3. The Joint Cognitive Systems Perspective
  4. Changing the Mindset: From Blaming Human Error to Systemic Thinking
  5. The Benefits of Adopting a Systemic Approach to Safety 
  6. Conclusion

The Problem with Blaming Human Error

When accidents occur, it's easy to point fingers at individuals and label their actions as the primary cause. This simplification may offer a sense of closure and even lead to punitive actions against the individuals involved. However, this approach often overlooks the complex web of contributing factors and systemic weaknesses that may have allowed the error to occur in the first place.

Human error is inevitable. People are fallible, and mistakes will happen. By attributing accidents solely to human error, we miss the opportunity to investigate the multitude of causes and learn from the incidents. This failure to learn can result in the same mistakes being repeated, leading to further accidents and potential harm.

The Systemic Approach to Safety

A more holistic and effective approach to understanding accidents and improving safety is to focus on the system as a whole. This approach, sometimes referred to as Safety-II or the systemic approach, recognises that human error is often a symptom of deeper issues within the system. These issues can include poor design, inadequate training, insufficient communication, or lack of appropriate safety measures.

By investigating and addressing these systemic factors, organisations can create more resilient systems that can better accommodate human variability and reduce the risk of accidents. This approach ultimately benefits both the individuals working within the system and the organisation as a whole.

The Joint Cognitive Systems Perspective

The joint cognitive systems perspective is an essential aspect of the systemic approach to safety. This perspective views humans and technology as integral parts of a single cognitive system, emphasising their interdependence and collaboration in achieving goals and maintaining safety. This approach considers the following key aspects:
  • Collaboration: Human and technological components work together, relying on each other's strengths and compensating for weaknesses.
  • Adaptability: Joint cognitive systems are adaptable, adjusting to changing conditions or unexpected situations.
  • Complementarity: Human and technological components complement each other, with each contributing unique capabilities.
  • Distributed cognition: Knowledge and information are distributed across human and technological components, with effective communication and coordination being crucial for achieving system goals.
  • Continuous learning: Joint cognitive systems are built upon the principle of continuous learning and improvement.

Adopting the joint cognitive systems perspective helps organisations design and manage complex systems that account for the dynamic interplay between human and technological components. This approach ultimately leads to more resilient systems that can handle the challenges of high-risk environments and maintain safety in the face of human variability and the unexpected.

Changing the Mindset: From Blaming Human Error to Systemic Thinking

Organisations must undergo a combination of education, communication, and cultural change to move away from a blame-oriented culture and adopt a systemic approach to safety. Here are some steps to facilitate this shift:

  • Education and training: Educate leaders and employees about the limitations of focusing on human error and the benefits of a systemic approach to safety through safety courses, workshops, or seminars.
  • Encourage a just culture: Promote a culture that encourages open reporting of incidents and near-misses without fear of punishment, balancing accountability with learning and improvement.
  • Lead by example: Senior leaders should demonstrate their commitment to a systemic approach by participating in safety initiatives, acknowledging their own fallibility, and promoting a culture of continuous learning and improvement.
  • Foster collaboration: Encourage cross-functional collaboration and communication, involving employees from different departments and levels in safety discussions and decision-making processes. This collaboration can help identify systemic weaknesses and latent failures that might have been overlooked otherwise.
  • Learn from successes and failures: Establish processes to review and analyse both accidents and successful operations to identify potential areas for improvement. By learning from negative and positive events, organisations can gain valuable insights into the factors contributing to safety.
  • Implement systemic changes: Based on the insights gathered from incident analysis and collaborative discussions, make necessary changes to policies, procedures, and equipment to address systemic weaknesses and reduce the likelihood of accidents.
  • Monitor and adjust: Regularly review and assess the effectiveness of implemented changes and adjust strategies as needed. Continuous monitoring and adjustment help ensure that the organisation stays on the right path toward improved safety and resilience.

The Benefits of Adopting a Systemic Approach to Safety

By shifting the focus from blaming human error to understanding and addressing the various causes of accidents, organisations can enjoy several benefits:

  • Improved safety performance: A systemic approach can reduce accidents and incidents by addressing the underlying weaknesses in the system.
  • Enhanced employee morale: By promoting a just culture that values learning and improvement over blame, employees will feel more engaged, empowered, and motivated to contribute to safety initiatives.
  • Strengthened reputation: Organisations that demonstrate a genuine commitment to safety and continuous improvement will gain a positive reputation among stakeholders, including customers, regulators, and the public.
  • Cost savings: Reducing accidents and incidents can lead to cost savings by avoiding lost productivity, damage to equipment, and potential legal liabilities.
  • Better decision-making: A systemic approach fosters a deeper understanding of the organisation's operations, leading to more informed decision-making and more effective resource allocation.


Organisations that are quick to blame human error for accidents and incidents often miss the opportunity to learn from these events and make meaningful improvements to their systems. Organisations can create more robust, resilient systems that protect workers and the public by adopting a systemic approach to safety and focusing on the contributing factors and systemic weaknesses that lead to human error.

Shifting the mindset of organisations and senior leaders from blaming human error to adopting a more systemic approach requires a combination of education, communication, and cultural change. By following the steps outlined in this article, organisations can transition from a blame-oriented culture to one that values learning, improvement, and systemic thinking, ultimately leading to safer working environments for all.

Are you tired of a blame-oriented culture that hinders your organisation's safety and resilience? It's time to adopt a systemic approach to safety. By understanding the complex web of contributing factors and systemic weaknesses that lead to accidents, you can create more robust and resilient systems that protect your workers and the public.

Education, communication, and cultural change are essential to shift your organisation's mindset from blaming human error to adopting a systemic approach to safety. Take steps to encourage a just culture, foster collaboration, learn from successes and failures, and implement systemic changes.

By adopting a systemic approach to safety, your organisation can enjoy improved safety performance, enhanced employee morale, strengthened reputation, cost savings, and better decision-making. Don't wait until the next accident happens. Make the shift to systemic thinking and create safer working environments for all.

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Topics: Organisational Resilience, Safety Differently, Safety II