Rethinking Human Error: Embracing System Failures for Modern Safety

By Michael Matthew — Safety.Inc | Certified Health & Safety Consultant | Operational Risk Management Professional

When accidents happen, the immediate reaction often points to "human error" as the cause. This phrase has become a default explanation, but it oversimplifies complex situations and unfairly blames individuals. A modern safety mindset calls for a shift in perspective: stop calling it human error and start calling it a system failure. This change in language reflects a deeper understanding of how safety works and how organizations can truly improve.

Control room with safety monitoring systems

Control room with safety monitoring systems illustrating the complexity behind safety management

Why Human Error Is a Misleading Term

Labeling incidents as human error suggests that the person involved is solely responsible. This view ignores the environment, tools, processes, and culture that shape human actions. People do not operate in isolation; they work within systems designed by others. When something goes wrong, it often reflects weaknesses in these systems rather than individual carelessness.

For example, a nurse administering the wrong medication dose might be blamed for a mistake. But if the medication labeling is confusing, the workload is excessive, or the electronic health record system is poorly designed, these factors contribute heavily to the error. Calling it human error hides these root causes.

Understanding System Failures

A system failure means that the structures supporting human work did not function as intended. This includes:

• Processes that are unclear or overly complex

• Equipment that is unreliable or hard to use

• Communication breakdowns among team members

• Training that does not prepare workers for real situations

• Work environments that increase stress or distraction

  
  

When these elements fail, they create conditions where mistakes become more likely. Recognizing system failures helps organizations identify and fix underlying problems rather than punishing individuals.

Examples of System Failures in Different Industries

Aviation

The aviation industry has long embraced the idea that accidents result from system failures. After thorough investigations, reports often reveal multiple contributing factors such as poor maintenance schedules, inadequate pilot training, or confusing cockpit controls. This approach has led to safer skies by improving systems rather than blaming pilots alone.

Healthcare

Hospitals have started to adopt system-focused safety models. For instance, the introduction of standardized checklists for surgeries reduces errors by ensuring every step is followed. When errors occur, root cause analyses look beyond the person involved to examine workflow, equipment, and communication.

Manufacturing

In factories, system failures might include outdated machinery, unclear safety protocols, or insufficient supervision. Companies that focus on improving these systems see fewer accidents and higher productivity.

How to Shift from Blaming People to Fixing Systems

Changing the mindset from blaming individuals to improving systems requires effort and commitment. Here are practical steps organizations can take:

• Encourage reporting of near misses and errors without fear of punishment

• Analyze incidents to identify system weaknesses, not just human mistakes

• Design processes that are simple, clear, and user-friendly

• Invest in training that reflects real work conditions and challenges

• Improve communication channels among teams and departments

• Regularly review equipment and tools for usability and safety

  
  

This approach builds a culture of safety where everyone feels responsible and supported.

The Role of Leadership in Embracing System Failures

Leaders set the tone for how safety is viewed. When leaders focus on system improvements, they create an environment where employees trust that reporting problems leads to solutions, not blame. This trust encourages openness and continuous learning.

Leaders can:

• Model transparency about mistakes and lessons learned

• Allocate resources to safety improvements

• Recognize teams for proactive safety efforts

• Foster collaboration across departments

  
  

Strong leadership commitment is essential to sustain a system-focused safety culture.

Benefits of Viewing Safety as a System Issue

Adopting this mindset brings several advantages:

• Reduced accidents by addressing root causes

• Improved employee morale as workers feel supported, not blamed

• Better compliance with safety regulations through clear processes

• Increased efficiency by streamlining workflows and reducing errors

• Stronger reputation as a safe and responsible organization

  
  

These benefits contribute to long-term success and resilience.