Why Didn't They Just Follow the Procedure?

It is often said that to err is human and that procedures are in place to prevent people from making mistakes. It's true that failures can be traced to human limitation, but what's more important is that all successes, all safe operations are the result of human capabilities. And while it's true that good procedures can help avoid error, it's also the case that procedures have their own limitations. This talk highlights the limits of procedures and the resilience people bring to operations. It discusses ways to change the common narrative that people are the creators of safety rather than only the source of error and failure, and it proposes an approach to the design of procedures that supports the human operator.