4

Workers Don’t Cause Failure,

Workers Trigger Failure
“Cause is not found in the rubble. Cause is created in the minds of the
investigators…”
Sidney Dekker, The Field Guide to Understanding Human Error

Questions about Your Organization:

• How long would it take to find a worker at my organization not following

a procedure?
• Does not following an organizational procedure always create an
immediate failure?
• Why is it when we have an event that we attribute that event to a failure
by the worker to follow procedures?

Remember: Three Parts of a Failure

Copyright © 2012. Ashgate Publishing Ltd. All rights reserved.

Every event you will have or have had in your organization is actually made up
of three distinctly different parts:

1. The Context of the Failure: This is everything that led up to the

actual event. This is the worker, the worker’s mindset, the environment,
the people, the hazards, the planning, and everything else that make
up the story of the failure. Remember, in the context section of the
event there is much information that the worker does not or cannot
know—for example, how the event will end.
2. The Consequence of the Failure: This is what happened, the effect
of the failure, the damage or harm, the deviation from the expected
behavior. This is the ending of the event.
3. The Retrospective Understanding of the Failure: This is how the
organization views the failure or deviation from the expected behavior.
It is at this point that all knowledge is available about this failure. The
retrospective has almost superhuman knowledge of every facet of this
event. This is when most organizations look for a cause—a specific
Conklin, Todd, Dr. Pre-Accident Investigations : An Introduction to Organizational Safety, Ashgate Publishing Ltd,
2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/portsmouth-ebooks/detail.action?docID=976591.
Created from portsmouth-ebooks on 2018-12-31 13:53:56.