An Ethic in Error for Safety

An Ethic in Error for Safety

The mistakes quadrant below is similar to the Unknown Knows quadrant or any other Johari window semiotic that seeks to understand something. Generally one names the criteria one wants along the x and y axis to explain various differentiations on a topic. The window below, does so regarding mistakes. It is important to realize that such constructs are not actual but projections and attributions based on Hindsight Bias (https://www.verywellmind.com/what-is-a-hindsight-bias-2795236). When one goes about ordinary life and mistakes occur, we only know much later whether the mistake was favourable or unfavourable.

This of course is not the case with zero harm acolytes, they make no mistakes, there is no fallibility (https://www.humandymensions.com/product/fallibility-risk-living-uncertainty/ ).

It is always interesting to read zero harm literature and find the omission of fallibility. However, this is not just in zero harm literature but mainstream safety literature. In many safety discussions about error there is no mention about personhood or the nature of fallibility (eg. Peterson, Kletz, Dekker, Reason, Wallace and Ross).

The omission discussion about: human ontology, fallibility and personhood is the safety elephant in the room. The omission of discussion about human personhood comes about because Safety only has a focus on systems and humans are considered as a ‘factor’ in a system. Hence the darling of safety science ‘human factors’ that doesn’t consider humans as humans.

One cannot consider the issue of error/mistakes without first articulating an Ethic of Risk, including a position on personhood. The idea that humans are a sub-set of a system is a projection. Humans don’t live their lives as if they serve systems, humans step outside of systems and chose whether to follow systems or not.

Humans don’t serve systems but rather create systems to serve them.

So if you read some of the projections made about human error in safety literature you see: pyramids and swiss cheese (Peterson), operating wrong valves (Kletz) metaphors of tunnels (Dekker), Reason (mechanistic metaphors) and taxonomies (Wallace and Ross) but no discussion on personhood or an Ethic of Risk.

In safety literature about error, human personhood is not discussed. Instead humans as a ‘factor’ in a system is assumed.

In human error discussion, much of the literature available from a Transdisciplinary approach is not considered. Eg.

· Arendt, H., (1958) The Human Condition.


· Bateson, G., (1972) Steps to an Ecology of Mind.

· Benner, D., (2016) Human Being and Becoming, Living the Adventure of Life and Love.

· Fowler, C., (2004) The Archeology of Personhood, An anthropological approach.

· Hallinan, J., (2009) Why we make Mistakes.

· Hassin, R., Uleman, J., and Bargh, J., (2005) The New Unconscious.

· Kirkwood, C., (2012) The Persons In Relational Perspective.

· Klein, N., (2005) a new operating manual for being human.

· Martin, J., Sugarman, J., and Hickenbottom, S., (2010) Persons, Understanding Psychological Selfhood and Agency.

· Neville, B., (1989) Educating Psyche, Emotion, Imagination and the Unconscious in Learning.

· Norretranders, T., (1991) The User Illusion, Cutting Consciousness Down to Size.

· Ricoeur, P., (1986) Fallible Man.

· Sheen, F., (1983) On Being Human.

· Schwartz, H. (2013) The Human being, A Theological Anthropology.

· Macaulay, R., and Barrs, J., Being Human, The Nature of Spiritual Experience.

· Semler, L., Hodge, B., and Kelly, P., (2012) What is Human? Australian Voices From the Humanities.

· Splitter, L., (2015) Identity and Personhood, Confusions and Clarifications across the Disciplines.

How convenient for Safety to bring to the table on error a complete silence on personhood. How bizarre for Safety to put forward an idea of ethics (AIHS BoK Chapter 38) without any discussion on humans as persons.

Poor old Safety, stuck in its own mono-disciplinary box (https://safetyrisk.net/transdisciplinary-safety/) trying to keep the elephant out of the room.

Until Safety engages with other disciplines and opens up its curriculum to views outside of the STEM comfort zone (https://safetyrisk.net/transdisciplinary-thinking-in-risk-and-safety/ ), it’s not likely we will ever see a holistic approach to very much including, looking to the traditional Safety view for a ‘new view’ dressing up the emperor in nothing ‘new’.

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Dr Rob Long

Expert in Social Psychology, Principal & Trainer at Human Dymensions

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PhD., MEd., MOH., BEd., BTh., Dip T., Dip Min., Cert IV TAA, MRMIA Rob is the founder of Human Dymensions and has extensive experience, qualifications and expertise across a range of sectors including government, education, corporate, industry and community sectors over 30 years. Rob has worked at all levels of the education and training sector including serving on various post graduate executive, post graduate supervision, post graduate course design and implementation programs.