Frederick C. Gamst
Abstract
The customary focus of internal and external investigations of human error on US railroads is the individual. For undistorted understanding of errors, and resulting accidents, we must understand the power structure in the hierarchy of levels of error. At the highest level, a state society and its culture(s) generate human errors. Below this are the errors from legislation, its executive enforcement including by regulatory agencies, and their judicial interpretations. Next, we reach the level of error from organizations, in actions and inactions of managers. At the bottom of the levels of error causation are the team and, then, the individual whose error is ordinarily not in isolation but shaped by errors on the higher levels. When supra-individual error remains uncountered, then, efforts to reduce error frequency in a workplace are largely ineffective.
Keywords: Human Error, Societal Levels, Organizations, Regulation, Railroads
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