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The Field Guide to Understanding Human Error

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Sidney Dekker

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“This is at the heart of the professional pilot’s eternal conflict,” writes Wilkinson in a comment to the November Oscar case. “Into one ear the airlines lecture, “Never break regulations. Never take a chance. Never ignore written procedures. Never compromise safety.” Yet in the other they whisper, “Don’t cost us time. Don’t waste our money. Get your passengers to their destination—don’t find reasons why you can’t.”

InvestigationHuman ErrorAviation History
Book:The Field Guide to Understanding Human Error
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“Valujet flight 592 crashed after takeoff from Miami airport because oxygen generators in its cargo hold caught fire. The generators had been loaded onto the airplane by employees of a maintenance contractor, who were subsequently prosecuted. The editor of Aviation Week and Space Technology “strongly believed the failure of SabreTech employees to put caps on oxygen generators constituted willful negligence that led to the killing of 110 passengers and crew. Prosecutors were right to bring charges. There has to be some fear that not doing one’s job correctly could lead to prosecution.”13 But holding individuals accountable by prosecuting them misses the point. It shortcuts the need to learn fundamental lessons, if it acknowledges that fundamental lessons are there to be learned in the first place. In the SabreTech case, maintenance employees inhabited a world of boss-men and sudden firings, and that did not supply safety caps for expired oxygen generators. The airline may have been as inexperienced and under as much financial pressure as people in the maintenance organization supporting it. It was also a world of language difficulties—not only because many were Spanish speakers in an environment of English engineering language: “Here is what really happened. Nearly 600 people logged work time against the three Valujet airplanes in SabreTech’s Miami hangar; of them 72 workers logged 910 hours across several weeks against the job of replacing the ‘expired’ oxygen generators—those at the end of their approved lives. According to the supplied Valujet work card 0069, the second step of the seven-step process was: ‘If the generator has not been expended install shipping cap on the firing pin.’ This required a gang of hard-pressed mechanics to draw a distinction between canisters that were ‘expired’, meaning the ones they were removing, and canisters that were not ‘expended’, meaning the same ones, loaded and ready to fire, on which they were now expected to put nonexistent caps. Also involved were canisters which were expired and expended, and others which were not expired but were expended. And then, of course, there was the simpler thing—a set of new replacement canisters, which were both unexpended and unexpired.”14 These were conditions that existed long before the Valujet accident, and that exist in many places today. Fear of prosecution stifles the flow of information about such conditions. And information is the prime asset that makes a safety culture work. A flow of information earlier could in fact have told the bad news. It could have revealed these features of people’s tasks and tools; these longstanding vulnerabilities that form the stuff that accidents are made of. It would have shown how ‘human error’ is inextricably connected to how the work is done, with what resources, and under what circumstances and pressures.”

InvestigationAccidentHuman ErrorAviation History
Book:The Field Guide to Understanding Human Error
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“How organizations deal with failures or accidents is particularly instructive. Pathological organizations look for a “throat to choke”: Investigations aim to find the person or persons “responsible” for the problem, and then punish or blame them. But in complex adaptive systems, accidents are almost never the fault of a single person who saw clearly what was going to happen and then ran toward it or failed to act to prevent it. Rather, accidents typically emerge from a complex interplay of contributing factors. [...] Thus, accident investigations that stop at “human error” are not just bad but dangerous. Human error should, instead, be the start of the investigation. Our goal should be to discover how we could improve information flow so that people have better or more timely information, or to find better tools to help prevent catastrophic failures following apparently mundane operations.”

ManagementOrganizational CultureOrganizational LeadershipTechCompany CultureSoftware DevelopmentHuman ErrorInformation Management
Book:Accelerate: Building and Scaling High Performing Technology Organizations
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“Blame and the punishment that follows may satisfy the thirst for vengeance. But we cannot punish and learn at the same time. Punishment keeps in place the belief that the system is safe and the human error was the aberration. Learning requires recognizing the failures built into the system and changing the system. Punishment has nothing to do with prevention.”

AccidentsNonfictionAccidentHuman ErrorHuman Errors
Book:There Are No Accidents
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