This report suggests that a new approach that seeks a deeper understanding of why errors occur would be more effective in encouraging safe practices in the future.
The failure to protect children from sexual abuse not only arouses shock and anger but also puzzlement: how could people who are employed to care for children fail to protect them when, with hindsight, the evidence of harm or danger seems all too obvious.
In the aviation and healthcare sectors, attributing failure simply to individual error is no longer seen as sufficient for encouraging safe practices in the future. Instead, attention has turned to seeking a deeper understanding of why errors occur. Failures are seen as consequences, not just causes. Solutions to failures are built on gaining a greater understanding of the factors that contributed to human error. Those factors lie in the nature of the activity being managed, the type of reasoning errors that people are prone to and the wider system in which workers operate.