What does the collapse of sub-prime lending have in common with a broken jackscrew in an airliner’s tailplane? These were systems that drifted into failure. While pursuing success in a dynamic, complex environment with limited resources and multiple goal conflicts, a succession of small, everyday decisions eventually produced breakdowns on a massive scale. The growth of complexity in society has outpaced our understanding of how complex systems work and fail. This book explores complexity theory and systems thinking to understand better how complex systems drift into failure.

Work has never been as safe as it seems today. Safety has also never been as bureaucratized as it is today. Over the past two decades, the number of safety rules and statutes has exploded, and organizations themselves are creating ever more internal compliance requirements. Bureaucracy and compliance now seem less about managing the safety of workers, and more about managing the liability of the people they work for. At the same time, progress on safety has slowed. Many incident and injury rates have flatlined. Worse, excellent safety performance on low-consequence events tends to increase the risk of fatalities and disasters.

Building on its successful predecessors, the third edition of The Field Guide to Understanding 'Human Error' will show a new way of dealing with a perceived "human error" problem in your organization. It will help you trace how your organization juggles inherent trade-offs between safety and other pressures and expectations, suggesting that you are not the custodian of an already safe system. It will encourage you to start looking more closely at the performance that others may still call "human error", allowing you to discover how your people create safety through practice, at all levels of your organization, mostly successfully, under the pressure of resource constraints and multiple conflicting goals.  

A just culture is a culture of trust, learning, and accountability. This third edition offers new material on restorative justice and ideas about why your people may be breaking rules. Supported by extensive case material, you will learn about safety reporting and honest disclosure, retributive just culture, and the criminalization of human error. If you learn to look at accountability in different ways, your impact on restoring trust, learning, and a sense of humanity in your organization could be enormous.

It is hard to change almost a lifetime of your organization’s thinking about safety in the traditional way and it is really difficult to change your organization’s history of bureaucracy that continues to reinforce the traditional safety definitions and metrics our organizations have used for many years. Let’s face it, change even for the better is hard to do. Doing Safety Differently is a discussion between two friends on what they have learned by watching organizations around the world change the way they do work.