From Blame to Prevention: The Role of Just Culture and Fault Tree Analysis in Managing Human Errors

The article proposes an approach to operator error through the application of fault tree analysis (FTA), an analytical tool commonly used in risk management. The aim is to address operator errors in a manner distinct from their automatic classification as disciplinary infractions. Complex operational environments, characterized by high demands, time pressure, and variable conditions, significantly increase the likelihood of errors due to cognitive limitations such as information overload or fatigue, as well as systemic factors like poorly designed interfaces, ineffective communication, and the absence of clear procedures. Managing operator errors requires more than identifying and correcting individual mistakes; it necessitates a systemic approach focused on preventing errors and minimizing their impact. By adopting such an approach, organizations can enhance trust and foster the development of a Just Culture - a framework that balances accountability with a commitment to learning and systemic improvement. This shift not only mitigates risks but also builds resilience and transparency within organizational processes.