uman and rganizational mor in Large Scale Systems

We are rarely interested in organizations that can do catastrophic harm until something happens in them to attract public attention. Yet when that event occurs we usually find the cause is not simply human error. More often, human error is embedded in organizational and societal processes that ultimately result in the error. The thesis of this essay is that we cannot fully understand the complex social processes that underlie either the reliable or unreliable operations of complex social and technical systems without examining such systems in their totality. The purpose of this paper is to identify some determinants of be- havior most important in understanding the operation of large scale systems in highly turbulent environments, and to suggest research that needs to be done to reduce error in these systems. We consider both active and Iatent failures. We propose that by effectively managing these determinants, potentially unsafe organizations can view and navigate the "safety space" more effectively, moving along the safety continuum toward more safe, rather than less safe, systems.