HUMAN AND ORGANIZATIONAL ERROR IN LARGE-SCALE SYSTEMS

We are rarely interested in organizations that can do catastrophic har m until something happens in them to attract public attention, Yet whe n that event occurs we usually find the cause is not simply human erro r. More often, human error is embedded in organizational and societal processes that ultimately result in the error. The thesis of this essa y is that we cannot fully understand the complex social processes that underlie either the reliable or unreliable operations of complex soci al and technical systems without examining such systems in their total ity. The purpose of this paper is to identify some determinants of beh avior most important in understanding the operation of large scale sys tems in highly turbulent environments, and to suggest research that ne eds to be done to reduce error in these systems. We consider both acti ve and latent failures. We propose that by effectively managing these determinants, potentially unsafe organizations can view and navigate t he ''safety space'' more effectively, moving along the safety continuu m toward more safe, rather than less safe, systems.