Skip to main content
Log in

The little engine who could not: “rehabilitating” the individual in safety research

  • Original Article
  • Published:
Cognition, Technology & Work Aims and scope Submit manuscript

Abstract

Safety science is one of the enduring enlightenment projects, which believes that rationality can create a better, more controllable world. Accidents are not seen as meaningless coincidences, but as failures of risk management, as something that can be improved in the future. The tragedy of safety research is that it has to simultaneously deny and affirm the primacy of human agency. As it has gradually expanded away from the sharp end to see accidents as bureaucratic or administrative in origin, the research keeps supplying linguistic and analytic resources that focus on individual shortcomings in leadership, communication or supervision. This paper concludes that individual human agency is useful to safety work, but not just as an instrument of political or organizational expedience. It is useful because it deeply reflects and reinforces how in the West we understand failure and success. The explanatory power of this discourse is confirmed or taken for granted by safety researchers because it appears so ordinary, self-evident and commonsensical.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  • Amalberti R (2001) The paradoxes of almost totally safe transportation systems. Saf Sci 37(2–3):109–126

    Article  Google Scholar 

  • Anon (2005) Murder! Mayhem! Social Order! Wilson Quarterly vol 29. Woodrow Wilson International Center for Scholars, Washington, pp 94–96

    Google Scholar 

  • Beck U (1992) Risk society: towards a new modernity. Sage Publications Ltd, London

    Google Scholar 

  • Bosk C (2003) Forgive and remember: managing medical failure. University of Chicago Press, Chicago

    Book  Google Scholar 

  • CAIB (2003) Report volume 1, August 2003. Columbia Accident Investigation Board, Washington, DC

    Google Scholar 

  • Cook RI, Nemeth CP (2010) ‘‘Those found responsible have been sacked’’: some observations on the usefulness of error. Cognit Technol Work 12:87–93

    Article  Google Scholar 

  • Dekker SWA (2003) Illusions of explanation: a critical essay on error classification. Int J Aviat Psychol 13(2):95–107

    Article  Google Scholar 

  • Dekker SWA (2005) Ten questions about human error: a new view of human factors and system safety. Lawrence Erlbaum Associates, Mahwah

    Google Scholar 

  • Dekker SWA (2011a) The criminalization of human error in aviation and healthcare: a review. Saf Sci 49(2):121–127

    Article  Google Scholar 

  • Dekker SWA (2011b) What is rational about killing a patient with an overdose? Enlightenment, continental philosophy and the role of the human subject in system failure. Ergonomics 54(8):679–683

    Article  Google Scholar 

  • DeVille K (2004) God, science, and history: the cultural origins of medical error. In: Sharpe VA (ed) Accountability: patient safety and policy reform. Georgetown University Press, Washington, pp 143–158

    Google Scholar 

  • Douglas M (1992) Risk and blame: essays in cultural theory. Routledge, London

    Book  Google Scholar 

  • Elkin F (1955) Hero symbols and audience gratifications. J Educ Sociol 29(3):97–107

    Article  Google Scholar 

  • Feldman SP (2004) The culture of objectivity: quantification, uncertainty, and the evaluation of risk at NASA. Human Relat 57(6):691–718

    Article  Google Scholar 

  • Foucault M (1975) The spectacle of the scaffold. Penguin Group, London

    Google Scholar 

  • Galison P (2000) An accident of history. In: Galison P, Roland A (eds) Atmospheric flight in the twentieth century. Kluwer, Dordrecht, The Netherlands pp 3–44

    Chapter  Google Scholar 

  • Gawande A (2002) Complications: a surgeon’s notes on an imperfect science. Picado, New York

    Google Scholar 

  • Giddens A (1991) Modernity and self-identity: self and society in the late modern age. Stanford University Press, Stanford

    Google Scholar 

  • Green J (2003) The ultimate challenge for risk technologies: controlling the accidental. In: Summerton J, Berner B (eds) Constructing risk and safety in technological practice. Routledge, London

    Google Scholar 

  • Hollnagel E (1998) Cognitive reliability and error analysis method: CREAM. Elsevier, Oxford

    Google Scholar 

  • Hollnagel E (2004) Barriers and accident prevention. Aldershot, UK

    Google Scholar 

  • Jensen C (1996) No downlink: a dramatic narrative about the challenger accident and our time. Farrar, Straus, Giroux, New York

    Google Scholar 

  • Levack BP (1987) The witch-hunt in early modern Europe. Longman, London

    Google Scholar 

  • Marx D (2001) Patient safety and the ‘‘just culture’’: a primer for health care executives. Columbia University, New York

    Google Scholar 

  • McLean B, Elkind P (2004) The smartest guys in the room: the amazing rise and scandalous fall of Enron. Portfolio, New York

    Google Scholar 

  • O’Neill B (2012) Concordia provides no morality tale. The Weekend Australian, Sydney, p 15

  • Pellegrino ED (2004) Prevention of medical error: where professional and organizational ethics meet. In: Sharpe VA (ed) Accountability: patient safety and policy reform. Georgetown University Press, Washington, pp 83–98

    Google Scholar 

  • Perrow C (1984) Normal accidents: Living with high-risk technologies. Basic Books, New York

    Google Scholar 

  • Pronovost PJ, Vohr E (2010) Safe patients, smart hospitals. Hudson Street Press, New York

    Google Scholar 

  • Reason JT (1990) Human error. Cambridge University Press, New York

    Book  Google Scholar 

  • Sagan SD (1994) Toward a political theory of organizational reliability. J Contingencies Crisis Manag 2(4):228–240

    Article  Google Scholar 

  • Salas E, Wilson KA et al (2006) Does crew resource management training work? An update, an extension, and some critical needs. Hum Factors 48(2):392–413

    Article  Google Scholar 

  • Shappell SA, Wiegmann DA (2001) Applying reason: the human factors analysis and classification system. Human Factors Aerosp Saf 1:59–86

    Google Scholar 

  • Silbey S (2009) Taming Prometheus: talk about safety and culture. Annu Rev of Sociol 35: 341–369

    Google Scholar 

  • Snook SA (2000) Friendly fire: the accidental shootdown of US Black Hawks over Northern Iraq. Princeton University Press, Princeton

    Google Scholar 

  • Turner BA (1978) Man-made disasters. Wykeham Publications, London

    Google Scholar 

  • Vaughan D (1996) The Challenger launch decision: risky technology, culture, and deviance at NASA. University of Chicago Press, Chicago

    Google Scholar 

  • Vaughan D (2005) System effects: on slippery slopes, repeating negative patterns, and learning from mistake? In: Starbuck WH, Farjoun M (eds) Organization at the limit: lessons from the Columbia disaster. Blackwell Publishing, Malden, pp 41–59

    Google Scholar 

  • Waterson P (2009) A critical review of the systems approach within patient safety research. Ergonomics 52(10):1185–1195

    Article  Google Scholar 

  • Weick KE, Sutcliffe KM (2007) Managing the unexpected: Resilient performance in an age of uncertainty. Jossey-Bass, San Francisco

    Google Scholar 

  • Young MS, Shorrock ST et al (2004) Who moved my (Swiss) cheese? The (r)evolution of human factors in transport safety investigation. International Society of Air Safety Investigators (ISASI), Gold Coast

  • Zimbardo P (2008) The Lucifer effect: understanding how good people turn evil. Random House, New York

    Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Sidney W. A. Dekker.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Dekker, S.W.A., Nyce, J.M. & Myers, D.J. The little engine who could not: “rehabilitating” the individual in safety research. Cogn Tech Work 15, 277–282 (2013). https://doi.org/10.1007/s10111-012-0228-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10111-012-0228-5

Keywords

Navigation