In the New View, the behavior which we call ‘human error’ is not a cause of trouble. It is the consequence, the effect, the symptom of trouble deeper inside your organization. The New View assumes that people do not come to work to do a bad job. So when there are bad outcomes, you must look beyond those people, at the conditions in which they worked at the time.

You and your organization may well have helped create those conditions. Leave those conditions in place, and the same bad outcome may happen again—no matter how many sanctions you impose, posters you put up or safety attitude campaigns you launch.

Sidney Dekker in The field guide to understanding human error.