There are two fundamental pathways to error prevention, the mechanical/mechanistic, and the human aspect. So can interventions or interlocks (upstream management efforts) really be pre-emptive, if they just depend on the individual, or can they be mostly effective? We need to consider the space between mostly and completely and how to work on it effectively. This is least apparent during the educating and training phase (black and white period) of the "good people" that we work with and exceedingly apparent during the recovery from an incident (grey period) caused by the "bad people" we work with.
Can human factors really bridge this gap, since we know that a system that depends on a human completely to prevent an accident is prone to failure? This thought process often seems to only be applied at the front end, where we rely on the adaptability of the individual to get the job done, but not on the back end where the same adaptations that result in success result in failure.
Most of our current methodologies when an incident occurs are dedicated
to trying to ascribe blame or error as causal, judging them, to be good or bad
and implicitly, judging people as being good or bad. This isn't so much an error or people trap, it is a response trap. We are all error-makers, who make mistakes, but for the most part, these errors don't lead to loss. Often times we put this lack of loss down to our own capacity, rather than the capacity built into the system (a second handrail on slippery stairs with high traffic up and down). Unfortunately, we can be slow to ascribe the same thinking to others and embrace the binary (good or bad) decision in this instance. They should have known better, so why shouldn't we?
The people that make an error are still the same well-intended, good people, they were before the error, so we need to give them and the process the same learning space rather than considering the binary immediately. We need leadership, to create a workplace where workers can be safe, successful and can effectively deliver information to that leadership on which to base informed decisions, especially after an incident. Don't rush to blame and punish, strive for inclusivity of cause and avoid making truth a second victim of the incident.
If leaders are aware of the conditions in the workplace that make the
error more likely, they need to address the conditions and feedback this information, to encourage and display trust, rather than dissemble.
When it comes to accountability, with 30 years of accident investigation, out of all of the folks that I have talked to there is no way that any system can hold them more accountable than they hold themselves.