As organizations struggle with a “human error problem”, they sometimes become willing to embrace a new, more productive understanding of safety, collectively called the “new look” or “new view” (Woods et al., 1994; Reason, 1997; Cook, 1998; AMA, 1998; Woods & Cook, 2002; Dekker, 2005). The new view sees “human error” not as a satisfactory conclusion to an investigation, or as a cause of trouble, but rather as the starting point; as a consequence of problems deeper inside the organization. Rather than saying what people should have done to not suffer the mishap, the new view tries to understand why what people did made sense to them at the time, as it may make sense to other practitioners too. It is thought that the new view is more productive since it leads stakeholders away from the illusion of quick fixes (rooting out isolated “causes” of failure) and towards more systemic changes that will allow the organization to learn and improve.
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