Instead of finding fault, tragic accidents could be more
preventable by using systems thinking.
Instead she looks at how accidents can be caused by unforeseen interactions between various components of a complex system.
“I don’t believe in blame,” Leveson says. “When it’s about blame, you just find someone to blame and then you go on.” Instead, she emphasizes making systems mistake-resistant, if not mistake-proof. “You need to design your system to prevent accidents, not depend on the operator,” she says.
Leveson contends that too many systems today are designed so that “we’re guaranteed the operator is going to make a mistake of some kind.” For example, a 2010 investigation of radiation oncology accidents by The New York Times found that while new technology helped doctors better attack tumors, the complexity of the technology also “created new avenues for error through software flaws, faulty programming, poor safety procedures or inadequate staffing and training.”
It's all the interactions among components of the process that tends to bring out unintended consequences. And it's failure to account for how humans actually tend to operate systems.
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