Comment by renewiltord

Any easy distillation loses crucial tail frequencies. I read The Design of Everyday Things by Don Norman and Understanding Human Error by Sidney Dekker back to back and it seemed to me that a lot of this was:

1. Have ergonomic procedures

2. Measure usage

3. Treat compliance failure as a problem with the procedure

4. Treat 100% compliance as evidence of lack of reporting

5. Defence in depth

If you want quick heuristics for a blind man, listen for "if they had just", "oh we never", "a competent X would have". All are signs your tools and procedures have problems. You should expect to have many low-level compliance failures but they should be uncorrelated (i.e. same person should not be making all the mistakes, many people should not be making the same mistake).

I am not a professional in this field, however, so take this with a grain of salt as my understanding based off what I read.