Classification of organizational failure root causes producing human error

The formal study of human error is relatively recent, especially in medical domain, and is tied closely to a several other relatively new fields. Organizational root cause of human error is less considered. Despite growing social, industrial and scientific interest in the organizational causes of incidents, the concept of organizational failure and related tools are still less considered in many developing countries e.g. Iran. Also, there is few incident record-keeping in medical domain on human error. Therefore, this study draws on case study research to investigate the applicability of a European taxonomy of organizational failure in Iran, in aviation domain with a fair incident record-keeping.

This case study resulted in 10 incident in-depth descriptions, which occurred during one year in a part of civil aviation due to operator error. Within each case study, an explanation building method is used to develop a tool for classifying organizational root causes. Results include 100 root causes. The distribution of organizational root causes over the main categories of the former taxonomy shows a need to add a new sub-category to improve its applicability in Iran. The new sub-category is related to culture.