The Field Guide › Paper
Read, Shorrock, Walker and Salmon review sixty years of thinking about human error, and the arc they trace is the one this map cares about most: the slow migration from blaming the person to interrogating the system. They begin with the awkward fact that the term itself is both blessing and curse. Its simplicity made ergonomics legible to outsiders and won the discipline a hearing, but that same simplicity licenses a lazy conclusion, that the operator erred, with real consequences for safety and for justice when investigators, media and courts stop looking the moment a human name is attached to a failure. The review then walks the theoretical lineage, from the early person-centred models of Rasmussen and Reason through to contemporary sociotechnical and complexity-informed approaches, and its central argument is that these are not just refinements but a change of paradigm. Complex systems, they insist, are indivisible, so the system rather than the individual has to be the unit of analysis; error is better understood as an emergent product of interacting conditions than as a discrete thing a person does. Systems methods therefore ask what combination of circumstances made this action reasonable to this person at this moment, rather than what the person got wrong. The authors are candid that the field's practice lags its theory, and that this systems view has largely failed to reach the media or the justice system, where human error still functions as an explanation and often as a verdict. For a corpus about psychological safety this is the definitive modern statement of the new view of error that underpins just culture, Safety-II and HOP. If error is systemic rather than personal, then punishing individuals for it is both unjust and counterproductive, and the willingness to report, question and surface what actually happened, which is to say psychological safety, becomes the mechanism by which a system learns about itself. Its limits are those of a review: it maps and evaluates a literature rather than testing it, and is stronger on the paradigm that should replace human error than on the practical methods for doing so at scale. (Text drawn from the 2021 Ergonomics paper, 64(9), pp. 1091-1114.)