People or systems? To blame is human. The fix is to engineer.

In my first week lecturing a course on safety and human performance, I introduced my students to the distinction between the person-centered and systems-centered approaches to managing safety (Reason, 2000; Woods & Cook, 1999). It was to be a simple, if mind-changing, lesson on eschewing the person-focused approach of blame, punishment, and empty intonations for workers to “Be safer!” Instead, I encouraged students to view safety as the emergent product of a complex socio-technical 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, I offered the example of a US Food and Drug Administration (FDA) recall of a medication infusion device whose mechanical components were contributing to over-tenfold medication overdoses of hospital patients (see box 1). The FDA recalled only those devices that were not yet installed in hospitals. For those devices that remained, the solution to the overdose problem was to train nurses to, essentially, “be safer,” and to place warning labels on the devices. After what I thought was a convincing lesson on the absurdity of fixing a human-device interface problem by focusing on anything but that interface, a student raised his hand, and dashed my hopes: Box 1 Infusion pumps are devices that control the flow of medication or other product into a patient through an intravenous (IV) line. An infusion pump manufactured by Alaris Products and used in many hospitals had a “key bounce” problem such that pressing a button once would sometimes register that keypress twice. For example, pressing 4.8 might result in “44.8” being entered, which represents a 10-time overdose. In August, 2006, the manufacturer was ordered by the US Food and Drug Administration (FDA) to send a letter to every hospital still using their device. The letter alerted hospitals to the problem and offered these “solutions”: (1) instructions for nurses to use a proper stance, listen to the number of keypress beeps, verify the screen display, obtain an independent double check, and look at the IV tubing to verify the correct flow rate; and (2) a warning label to be placed on each device. A simpler and more effective solution might have been to fix the mechanical key bounce problem. “Yes, I see how the manufacturer could make their product fool-proof, but it’s the user’s responsibility to not be a fool, in the first place.”1 To my surprise, another student agreed. I was instantly reminded of safety classes I had taken in college, when I had heard similar comments from my peers. In one such class, a particularly memorable student firmly insisted that accidents were 90% the fault of humans,2 and upon being encouraged by the professor to think it through, revised his estimate to 100%. These person-centered views are not confined to the protestations of students. 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, both of which are discussed below, suggest that there is something fundamental, perhaps universal, about the assignment of accident causality (and sometimes blame) to the actions and dispositions of human beings. The remainder of this article is organized as follows. First, a case is made that there is a tendency to attribute causality and blame to person factors. The tendency has been well described by psychologists who study what is known as 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, it is discussed how the newer trend in safety management of focusing on intentional safety protocol violations may be a pitfall if it simply reinforces the person-centered approach. Finally, the numerous implications of the human tendency and industry norm of focusing on the person are discussed. To foreshadow, the main implication is that person-centered tendencies engender ineffective person-centered solutions: …associated countermeasures are directed mainly at reducing unwanted variability in human behaviour. 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