Blame the Design, Not Just the Person

Think about the last time you pulled instead of pushed a door or failed to follow a series of instructions from a user manual. Chances are, you blamed yourself. “It’s just a simple set of steps; how could I mess that up?” we think. Rarely do we stop to consider if it was actually bad design that set us up to fail.

Dan Norman, in his book The Design of Everyday Things, highlights this phenomenon. He argues that organizations often adopt the same mindset. When something goes wrong, the knee-jerk reaction is to blame the human, not the system. But why the double standard? When a machine fails, we dive into root cause analysis. Was it a defect in materials? Environmental factors? Operational stress? Whatever the reason, the focus is on identifying and fixing the issue. Yet when it comes to humans, the conclusion is often simple: they failed to follow the process.

The Myth of Human Error

In his chapter, "Bad Design, No Human Error," Norman unpacks this tendency to blame people over systems. He points out that 75–90% of industrial accidents are attributed to human error. But if human error is consistently this high, shouldn’t we question whether the design itself might be the problem?

Blaming humans is convenient. It allows organizations to avoid deeper scrutiny. Unrealistic expectations of human performance are normalized—employees are expected to maintain perfect attentiveness for long hours, memorize complex emergency procedures, and never make mistakes under pressure.

Consider the movie Sully, based on the real-life emergency landing of US Airways Flight 1549. When the plane’s engines failed due to a bird strike, Captain Chesley "Sully" Sullenberger and his co-pilot had only seconds to make critical decisions. Despite successfully landing the plane on the Hudson River and saving all 155 lives onboard, initial blame fell on Sully. The focus was on whether he had made the “right” decision instead of asking if the system could have been designed to better support pilots in such unprecedented situations.

Why Organizations Blame People Instead of Design

The tendency to blame humans instead of systems boils down to three factors:

1. It’s Easier: Root cause analysis and design overhauls are time-consuming and costly in the short term. Pointing fingers is a quicker fix.
2. Deflecting Accountability: Acknowledging design flaws often shifts the responsibility from individuals to the organization. This accountability can be uncomfortable, especially for those at the top.
3. Self-Preservation: Organizations are made up of individuals who prioritize their positions and reputations. Admitting systemic flaws can feel like admitting personal failure, which many resist.

Learning from Companies That Prioritize Design

Not all organizations fall into this trap. Toyota, for example, is known for its relentless focus on design and process improvement. By embedding high standards and accounting for exceptions in its design principles, the company minimizes errors. While this approach may involve higher upfront costs, it pays off in long-term reliability and quality.

Contrast this with Boeing’s recent struggles. In a mishap involving an Alaska Airlines Boeing 737, a mid-air decompression incident was linked to missing bolts in the window assembly. The company’s CEO resigned, and while leadership accountability is important, the underlying question remains: what systemic design flaws allowed such an oversight to occur in the first place?

Shifting the Narrative: From Blame to Design

Blaming individuals might provide temporary relief. Replacing a leader or adding stricter guidelines can create the illusion of improvement. But unless organizations reframe errors as opportunities to improve design, they risk stagnation. Exceptional quality and continuous improvement come from creating systems that are resilient to human fallibility, not from assuming humans can operate flawlessly.

To truly excel, organizations must foster a culture that first questions the design rather than the user. This shift requires effort, investment, and, most importantly, empathy. After all, it’s not just about fixing errors; it’s about ensuring they don’t happen again. So, the next time something goes wrong, pause before pointing fingers. Ask: is it really human error—or could it be bad design?