“Human Error or System Failure”? Rethinking the Root Cause of Safety Incidents”

When safety incidents happen, the first reaction is often to ask: “Who made the mistake?”

But in many cases, that question misses the bigger issue.

Workers and the systems they operate are closely connected. Both have limitations. Complex systems, confusing controls, unclear procedures, poor communication, and undocumented workarounds can all create conditions where mistakes are more likely to happen.

Too often, organizations focus only on the person involved in the incident instead of looking deeper at the system surrounding them.

At Rev1 Energy, we believe that safety incidents are rarely caused by one action or one person. More often, they are the result of multiple breakdowns in systems, communication, procedures, and leadership.

When Systems Create Opportunities for Error

Many systems are designed with unnecessary complexity.

For example, imagine a control panel with rows of identical buttons that all perform different functions. Even when they are labeled, the design itself makes it easier for an operator to press the wrong button.

In situations like this, the system may technically function—but it may not be designed in a way that helps people succeed.

Contributing factors often include:

• Cost limitations
• Time pressures
• Production demands
• Poor system design
• Lack of user input during development
• Overly complex procedures

When systems are difficult to understand, workers often find ways to adapt in order to keep work moving.

The Role of Tribal Knowledge

One of the most common signs of a broken or overly complex system is the development of “tribal knowledge.”

Tribal knowledge is the informal way people learn how things actually work, especially when official procedures do not match reality.

You hear it in phrases like:

• “We all know that process doesn’t really work.”
• “That’s not how we actually do it.”
• “The experienced operator showed me the shortcut.”
• “The manual says one thing, but in the field we do another.”

Tribal knowledge is not always negative. In many cases, it develops because workers are trying to make the system work more effectively.

However, when undocumented workarounds become normal, they can create hidden risks that leaders may never see until something goes wrong.

Human Error and System Failure Work Together

Systems can make people fail, and people can make systems fail.

Workers often adapt to overcome flaws in equipment, procedures, or communication gaps. Over time, these workarounds can become accepted as “the way things are done.”

The challenge is that these behaviors often remain invisible until an incident occurs.

When investigating root causes, organizations should not stop at the immediate action that caused the event. Instead, they should ask:

• Why was the worker in that position?
• Why did the system allow the error to happen?
• Why did the workaround become normal?
• Why was the issue not documented or corrected earlier?

These questions help uncover the deeper conditions that contribute to incidents.

Why Root Cause Investigations Need to Go Deeper

Many organizations focus too heavily on identifying one root cause.

In reality, most incidents involve multiple failures happening at the same time:

• A confusing process
• Poorly designed equipment
• Incomplete training
• Unclear procedures
• Communication gaps
• Time pressure
• Leadership decisions
• Lack of documentation

The goal should not be to assign blame as quickly as possible. The goal should be to understand the sequence of events and identify the conditions that made failure more likely.

This is where interviews, learning teams, field observations, and conversations with workers become valuable.

The more time leaders spend understanding how work is actually performed, the easier it becomes to identify weak signals before they lead to an incident.

Moving from Reactive to Proactive Safety

One of the strongest indicators of a healthy safety culture is the ability to identify risks before an event happens.

Examples of proactive thinking include:

• “This process is too complex and could lead to mistakes.”
• “Operators are relying on undocumented workarounds.”
• “This equipment setup is confusing.”
• “People are finding shortcuts because the procedure is difficult to follow.”

Recognizing these signals early allows leaders to make changes before injuries or failures occur.

A proactive safety mindset focuses on improving systems, simplifying processes, and removing barriers that make it harder for workers to succeed safely.

The Leadership Responsibility

Leadership plays a critical role in shaping whether organizations blame workers or improve systems.

Strong leaders:

• Spend time in the field
• Ask questions before incidents happen
• Encourage honest conversations
• Look for patterns and weak signals
• Create systems that are easier to use
• Support workers instead of immediately blaming them

When leaders respond quickly to concerns and take action to improve systems, they can dramatically change the conditions of a site, project, or organization.

At Rev1 Energy, we believe that understanding why people work around systems is just as important as understanding why incidents happen.

The goal is not simply to find fault—it is to build better systems, better procedures, and better outcomes. Because when leaders look beyond “human error” and start improving the conditions surrounding work, they create safer, stronger, and more reliable operations.