“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. I”