In this webinar, David Wilbur, Vetergy Group CEO and Founder, discusses how human error is inevitable and serves as a symptom of systemic failure. As with all symptoms, it becomes a signal spurring systemic change. The idea is to welcome error as an indication that leadership should investigate the dark, murky, uncomfortable cultural issues that made the error seem like a good idea at the time. Instead of blaming individuals for error, ask why the system responded the way it did.
In a real-world example, Wilbur studies an organization’s emergent behavior through the actions of two operators. As a rule, these operators did not set out to cause failure; rather, they intended to contribute to the larger success of the organization. Nevertheless, as part of a multi-dimensional operating framework, they were shepherded by complex events into making decisions that instead caused an incident.
Fittingly in today’s health and economic conditions, Wilbur relates how lessons from this incident explain why organizations are experiencing an uptick in performance as operating models are dynamically adapted to respond.
For more information on how to incorporate human factors analysis into your investigation program, click here or email us at info@vetergy.com. And check out how you can take Vetergy's Virtual HFACS course offered monthly. Click here for the full schedule of events.