If human errors were mosquitoes, living in a swamp, would we kill them one-by-one, or would we drain the swamp?
This example illustrates two ways of thinking, which can guide a safety intervention in two, completely different directions. On the one hand, an accident can be seen as a result of human error, which is therefore the cause; or, on the other hand, it can be seen as a symptom of a failure in the system architecture, human error becoming a consequence. If we adopt this second approach, human error – and the resulting accident – become the starting point for the analysis…