People or Systems?
To blame is human. The fix is to engineer. By Richard J. Holden

During a lecture in a safety ad human performance course, students were told about the distinction between the person-centered and systems centered approaches to managing safety (Reason, 2000;Woods & Cook, 1999). Thiswas to be a simple, if mindset-changing, lesson on eschewing the person focused approach of blame, punishment and empty intonations to be safe. Instead, students were encouraged to view safety as the emergent product of a complex sociotechnical system. The implication is that changes in safety can only come about through changes that address not only people, but also the many system components with which people interact.
To illustrate the point, the students are told about a Food and Drug Administration (FDA) recall of a medication infusion device whose mechanical components were contributing to medication overdoses (sidebar, p. 35). FDA recalled only those devices not yet installed. For those devices that remained, the solution was to train nurses to essentially “be safer” and to place warning labels on the devices. The lecturer expected this would be a convincing
lesson on the absurdity of fixing a human-device interface problem by focusing on anything except that interface. But a student raised an unexpected
objection: “Yes, I see how the manufacturer could make its product fool-proof, but it’s the user’s responsibility to not be a fool in the first place.” Another student agreed. This recalls common assertions that accidents are largely the fault of humans. In fact, in the first half of the 20th century, some estimated that 88% of accidents were caused by the unsafe acts of workers (Heinrich, Petersen & Roos, 1980). [Author’s note: A systems-centered approach need not suspend individual responsibility (in this case trained and licensed professionals), but it is unlikely that the overdoses were due to foolishness or a lack of responsibility, as the student implied.] The student erred in presuming that mistakes were being caused primarily and deliberately by humans. These person-centered views are not limited to student protestations. These views may even be a psychological tendency and an industry norm, despite teachings to the contrary. Psychological evidence about typical human behavior and a critical assessment of how accidents are handled in the modern world suggest that there is something fundamental, perhaps universal, about the assignment of accident causality (and sometimes blame) to the actions and dispositions of humans.
This article first makes a case about the tendency to attribute causality and blame to person factors. This tendency has been well described by psychologists
who study causal attribution theory (Harvey & Martinko, 2009; Malle, Knobe & Nelson, 2007). The tendency may also apply to managers, industry practitioners, official investigators and legislators who deal with safety on a daily basis, and some evidence is presented to support that contention.
Further, the trend of focusing on intentional safety protocol violations and how it may be a pitfall if it simply reinforces the person-centered approach is
discussed. Finally, the numerous implications of focusing on person factors are discussed. The main implication is that person-centered tendencies engender ineffective person-centered solutions: Associated countermeasures are directed mainly at reducing unwanted variability in human behavior. These methods include poster campaigns that appeal to people’s sense of fear, writing another procedure (or adding to existing ones), disciplinary measures, threat of litigation, retraining, naming, blaming and shaming (Reason, 2000, p. 768).

How Fundamental?
Ross (1977) found the person-centered approach to be so ubiquitous in society that he called it the fundamental attribution error. Researchers of the
phenomena have found that when people observe an action or outcome, they tend to attribute its cause to the actor’s internal or dispositional traits, even in
the face of overwhelming evidence that the action was caused by the situational context. For example, a worker who slips on a wet work surface may be said by observers to have fallen due to clumsiness, carelessness or inattention. Other findings from research on causal attributions (Fiske & Taylor, 1991) suggest that individuals 1) attribute the cause of action to external factors if they were the ones who performed the action, but to internal factors if they witnessed others performing it (the actor observer bias); 2) attribute others’ failures to internal factors but their own failures to external factors, and the reverse for successes (the self-serving bias); and 3) make inferences about a person’s character (e.g., dumb, motivated, risky) based on the actor’s observed actions, even when those actions are constrained by external factors (the correspondence bias). Despite much early research on causal attributions—more than 900 studies were published in the 1970s alone—the link between attribution theory and safety was not made explicit until the mid-1990s (Glendon, Clarke & McKenna, 2006). However, the importance of attribution in safetymanagement cannot be understated: Attributional processes are at the very heart of workplace safety management. Workers, supervisors, managers and safety specialists are all involved in making inferences of causality or attributions. . . . These causal inferences, in turn, broadly determine the actions that are taken or not taken to correct hazards and prevent injuries. In a very real sense, actions to manage safety derive more from attributions than from actual causes (DeJoy, 1994, p. 3). For technical precision, it is worth noting that causal attributions and blame are not identical concepts. In attribution theory, blame implies that the behavior was inappropriate, unjustifiable or intentional
(Shaver & Drown, 1986). Thus, blame is a special case of causal explanations. However, a person-centered causal attribution of workplace accidents need
not involve blame. Worker behavior can be seen as the cause of accidents even when the behavior itself is not attributed to impropriety or intentions of harm.
The causes of these attribution tendencies are still debated. They include the proposal that some cultural and educational systems promote individual agency and a focus on the individual (i.e., Western individualism); the high salience of human action (e.g., the noticeable nature of a human falling); the low salience of situational conditions especially if those conditions are chronic or latent (e.g., the less-observable daily stress, prior upstream managerial decisions or a slippery floor’s coefficient of friction); the cognitive difficulty of adjusting initial judgments or searching for multiple, interactive causes; and differences in experience with the action being attributed (e.g., supervisors who have more experience with a subordinate’s job are less likely to attribute accidents to subordinates). The cause of attribution tendencies is important (DeJoy, 1994). Causes aside, much evidence points to a general psychological tendency toward person-centered attributions. If this is the case, an SH&E professional might ask to what extent this tendency prevails in the world of contemporary safety management. In other words, is the person-centered approach an industry norm? Dekker (2002) addresses this question
when he writes of the bad apple theory of safety management. According to this theory, one “identifies bad apples (unreliable human components) somewhere in an organization, and gets rid of them or somehow constrains their activities” (p. 3). This theory belongs to the old view of human error, which states that:
Human error is the cause of many accidents. The system in which people work is basically safe; success is intrinsic. The chief threat to safety comes from the inherent unreliability of people. Progress on safety can be made by protecting the system from unreliable humans through selection, proceduralization,automation, training and discipline. (Dekker, 2002, p. 3). According to Dekker, the new view first succeeded the old view around the time when human factors pioneers Fitts and Jones were asked to advise the U.S. military on how to select less error prone fighter pilots. They instead discovered
that it was not the pilots but the planes’ design that needed to change in order to improve the compatibility between the plane and the pilot. This systems-centered view is credited with having saved many lives and dollars during World War II and the Korean War (Helander, 2006). According to the new view:
Human error is a symptom of trouble deeper inside the system. Safety is not inherent in systems. The systems themselves are contradictions between multiple goals that people must pursue simultaneously. People have to create safety. Human error is systematically connected to features of people’s tools, tasks and operating environment. Progress on safety comes from understanding and influencing these connections (Dekker, 2002, p. 3; Hollnagel & Woods, 2005).
Dekker is critical of the notion that the old view is a thing of the past, left behind in a pre-World War II era.He refers to “the reinvention of human error” as a modern-day resurgence of blame, a “retread of the old view” (p. 14). He argues that even in the 21st century safety management approach, the focus is too much on human failure and too little on flawed systems, too much on judgments and too little on explanations. Even when the worker or operator is not blamed, his/her boss is. He alleges that overly simplistic error classification and other modern safety management methods reinforce the old view, albeit unintentionally. Attributing causality and blame to the person remains the industry norm (Woods & Cook, 1999). An Empirical Test of Dekker’s Critique
To test Dekker’s critique that modern safety management has not abandoned the person-centered approach, National Transportation Safety Board’s
(NTSB) investigations of major aviation accidents (www.ntsb.gov/ntsb/major.asp) were examined. NTSB organizes investigations of accidents, including
all aviation accidents in the U.S. Based on analysis of accident sites, record reviews, interviews and more, NTSB produces a report that includes the attribution of probable causes and contributing factors.

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