When something goes wrong, there’s a strong instinct to blame the litigant, the client, the website user.  A recent example is this CNN story on unintended acceleration. (Its written in term of being the drivers fault).

An old friend once told me the story from almost two hundred years ago, when railroads were still new.  Apparently, head on collisions were categorized by railroads as “operator error” or “system error.”  There were lots of operator errors — the train operator going through the stop signal.

Then someone had the bright idea that having two tracks instead of one — one in each direction.  The result — many fewer “operator errors.”

The moral is obvious.  The only way you are going to get improvements is to assume that the error is “system error” and figure out how to change the system to prevent the error.

And sure enough, CNN does report ideas and attempts to do just that with unintended acceleration.

So please, whatever goes wrong, ask yourself how you can change the overall system so that even when people tend to make mistakes, the system prevents them doing harm.  Or put anther way, treat every bad outcome as a product of system error, and think about the design change that will prevent it.  That’s why air travel is so safe.  That’s been the philosophy of the system.

Comments?  How does this apply to the court context?