The Field Guide to Understanding Human Error

Dekker, Sidney. The Field Guide to Understanding Human Error. 2nd ed. Farnham, UK: Ashgate, 2006.

Why this matters here

Dekker’s Field Guide reframes “human error” as a starting point for investigation rather than a conclusion—looking at how people made sense of incomplete information inside the system they actually had. How Serious Systems Learn pairs that stance with reluctance to simplify: premature cause stories close corrective options while confidence is still unwarranted. The source challenges blame-as-explanation; the book treats durable ambiguity as an operational cost of avoiding stable misdiagnosis.

Read the relevant passage in How Serious Systems Learn

Open in graph

PreviousSidney Dekker — Drift into Failure: From Hunting Broken Components to Understanding Complex Systems

NextSidney Fine — Sit-Down: The General Motors Strike of 1936-1937

Related concepts4 concepts

Concept

Accountability

Accountability names whether consequence still reaches the people who can respond. It becomes important when scale, narrative, or abstraction thins contact between action and effect. It helps preserve correction and proportionate answerability, but can fail when moral sorting replaces sustained contact with outcomes. It differs from responsibility because accountability emphasizes exposure to consequence; responsibility includes the ongoing obligation to account even when control is partial.

View Concept →

Concept

Feedback

Feedback names how systems stay in contact with their own effects. It becomes important whenever action and consequence are separated by time, scale, or abstraction. It helps preserve learning, correction, and trust in ongoing coordination, but can fail when dashboards stay green while lived harm accumulates off the ledger. It differs from trust because feedback is the returning signal itself; trust is the bridge that lets people act before every signal arrives. It differs from correction because feedback is what returns; correction is the work of updating in response.

View Concept →

Concept

Harm

Harm names where cost lands when influence is exercised—who absorbs it, who is kept in view, and what displacement is treated as acceptable. It marks the lived consequence of action, authority, design, or coordination. The visibility dimension matters—who is harmed in particular, not on average? Can they name it? Can they respond? Does the system register it or treat it as acceptable loss? Harm continues while interpretation expands, briefings make harm legible without smaller, people can still tell when something is doing harm. The question harm raises—is harm unchanged outside while we analyze inside? When does naming harm substitute for reducing it? The failure mode—harm persists while moral work feels complete, delays continue after excellent postmortems, harm becomes statistical at scale. The restoration path—return to particular harms and people, check effects outside the room after briefings, stop when outcomes for people are unchanged, pair analysis with named remedy attempts, accept harm as inevitable without abandoning response.

View Concept →

Concept

Responsibility

Responsibility names what continues after action—the obligation to remain responsive to what one's choices set in motion. It becomes important when systems scale beyond any one person's control but moral weight still accumulates. It helps preserve sustained answerability, but can fail when responsibility collapses into futility or when symbolic gestures replace contact with effects. It differs from accountability because responsibility names the enduring relation; accountability names whether consequence still reaches those who can respond.

View Concept →

Related books1 book

Book
How Serious Systems Learn
Disciplines for Acting Without Certainty
A handbook for teams and institutions that need to learn in motion, improve under pressure, and make better decisions without waiting for perfect information.
View book