It is fascinating to read Reason’s book on Human Error where ‘fallibility’ is mentioned eleven times. Yet, when Safety wants to discuss its obsession with blame and cause, and when Reason is quoted, there is no mention of fallibility. Reason never defines fallibility nor has any discussion on mortality in his book.
In Dekker’s book on Human Error there is simply no discussion on fallibility or mortality at all. The focus on ‘human error’ is not defined by Dekker instead, it is placed in a discourse of ‘old’ and a ‘new view’ in a discussion of cause, symptom and system. The focus of the book is a re-framing of what error means (to Dekker) and how the discourse of ‘human error’ demonises safety.
In other works on Human Error published in Safety, there is a profound silence in discussion on fallibility, mortality, imperfection or any discussion about human ontology (theory of being). Indeed, in all the promotion of the ideology of zero and perfection, the reality of fallibility is missing.
Any silence in safety on the nature of fallibility, perfection and mortality sets up the industry for an ethical and moral dilemma.
Yet, I see in so many places (particularly in groups associated with S2, SD, RE, NV and HOP mythology) the rejection of ‘human error’ as a cause of events.
It seems when safety doesn’t like something it just wishes it away and the problem is gone. Indeed, the latest fad (promoted by the HOP cult) is that there is no blame and any error needs to be attributed to ‘the system’. Hey presto, the problem of blame and error is solved!
Of course, none of this is a reflection of reality or what happens in a court room when something goes wrong (https://safetyrisk.net/how-will-your-safety-propaganda-stand-up-in-court/).
A psychosis is any belief that is out of touch with reality. This is what we see when Safety wants to wish away fallibility, mortality and imperfection when these don’t suit its narrative. Yet, in a court setting where cause, blame and compensation are sought, human imperfection is accepted as a stark reality indeed, why the court is listening to a matter.
I wrote a book called Fallibility and Risk in 2018 (https://www.humandymensions.com/product/fallibility-risk-living-uncertainty/) to bring to light the reality of fallibility that risk and safety must live with but seeks to ignore or wish away.
The challenge for Safety is to develop a worldview that acknowledges fallibility and develop a better understanding of the nature of Everyday Social Resilience (https://www.humandymensions.com/product/everyday-social-resilience-being-in-risk/) as its essential by-product.
Prof. Robert Long
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Rosa Carrillo says
Why do legal frameworks define what is right action? Is the legal system always right? Or are there times when we need to disobey because it is the right thing to do? Fallibility and human error do not meet safety’s definition of root cause. “The purpose of naming the root cause is to prevent it from happening again.” We cannot prevent fallibility or all human error.
Rob long says
Hi Rosa, good questions. Whilst we rely on the legal system for justice, it is rarely its purpose. The courts do however understand fallibility whilst Safety does not. Indeed, rarely defines if discuses it. I don’t think Safety understands error either. As for root cause, just another myth.
Rosa Carrillo says
In what sense do the courts understand fallibility?
Rob Long says
It’s it build into most laws and rulings that humans are not perfect. In Safety this is anchored to ALARP and Due Diligence. In law in general and in legal curriculum in specifics, humans are understood as not being perfect and that the law is needed and the courts to arbitrate. It is also assumed in how evidence is surfaced and the knowledge that memory is not perfect. Lawyers study Ethics as a core in their curriculum and know about bias, prejudice and partiality. They know there is no such thing as impartiality or objectivity, Safety does not. This is why the system has judges and magistrates whose expertise and opinion is final in legal proceedings. It is also why case law is so important. It is not a perfect system but way more advanced than an industry that doesn’t study ethics, moral philosophy or myths of objectivity.
In the legal profession in Jurisprudence the nature of human fallibility is foundational to an understanding of memory and evidence, reliability and judgement. Most lawyers would have to study Rawls as a starting point in understanding the law and Rawls trawls over the issue of fallibility in his theory of Justice. Nothing like this is explored by anyone in safety, except for the book I wrote. Indeed, in the so called ‘safety differently’ HOP world, there is no study of this important worldview. In the same way we have all these so called experts in culture in safety and none discuss religion. Of course, this is why safety is not a profession, because of all it ignores and is silent on. Indeed, it has an aversion to moral philosophy and a study of ethics.
Rosa Carrillo says
Thank you Rob. I know very little about this topic, but my experience with lawyers and the legal system have been very negative. I’m sorry to say the lawyers I’ve met must have missed that part of their education. Except my good friend Kathy who is the most ethical, fair person I know.
Rob Long says
Yes, most experience with lawyers and the courts keep no-one happy. Such is the nature of he institution and profession. Whilst I am not a legal expert I have been in court many times and have that experience but when it comes to law defer to people like Greg Smith. Hence why we wrote the book and video series Risky Conversations. The legal profession and court system is an ethical minefield but it is what we have and serves us as best we may like. The trouble is many in safety who are pumped to the hilt with law, regulation and standards are NOT lawyers and are most often unhappy with the determinations of a court. The other aspect of the legal profession is that they do have a profession where lawyers can be disbarred or struck off for unethical practice. However, keeping within the lose nature of the law is not guarantee of ethical conduct. Most lawyers I know do the best for their client within the confines of what they know. It laso depends on what kind of law we are discussing: civil, criminal, family etc.
When I experienced in the Children’s Court system for 4 years in my role managing Galilee, I found it to be extraordinarily compassionate and understanding. I those days I used to meet with the Magistrate before proceedings and he he would consult about what I thought was the best outcome for the child. In such a consultation we got the best outcomes we could for such children and tried to keep them out of detention.