Distinguish system causes from individual causes in the analysis

Most failures have system causes and individual causes; fixing only the individual leaves the system to produce the same result again.

Why it works

Attribution research shows humans default to personal attribution ("I made a mistake") over situational attribution ("the system made this mistake easy to make"), especially in self-analysis. System causes — ambiguous processes, missing information, misaligned incentives — tend to recur until addressed structurally. Individual-level fixes on system problems produce temporary improvement followed by relapse.

How to do it

1. In the causal analysis, ask both: "What did I do that contributed?" and "What about the situation or system made this outcome more likely?"
2. For recurring gap patterns across multiple AARs, specifically look for the system cause rather than applying the individual fix again.
3. Implement system changes (checklists, process modifications, environment redesigns) when a pattern repeats more than twice.

Evidence

Human factors and safety research consistently finds that system-level contributing factors are underweighted in post-event analyses, and that individual-blame responses leave error-producing systems intact. (clinical)

Safety engineering research focuses on high-consequence domains; the system-vs-individual attribution principle generalises to personal productivity and performance, but the stakes and stakes-structure differ.

Sources

• Reason (2000), "Human error: models and management", British Medical Journal

Common mistake

Resolving the same gap with the same individual-level fix repeatedly without asking whether the system is reliably producing the gap despite individual effort.