More and more often the blame is attributed to "human error." The person involved can be fined, punished, or fired. Maybe training procedures are revised. The law rests comfortably. But in my experience, human error usually is a result of poor design: it should be called system error. Humans err continually; it is an intrinsic part of our nature. System design should take this into account. Pinning the blame on the person may be a comfortable way to proceed, but why was the system ever designed so that a single act by a single person could cause calamity? Worse, blaming the person without fixing the root, underlying cause does not fix the problem: the same error is likely to be repeated by someone else.
( Donald A. Norman )
[ The Design of Everyday Things ]
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