Error Management: Achievements and Challenges (Have we made a difference?)

1. HFG Conference, RAeS, 15 October 2003 Error Management: Achievements and Challenges(Have we made a difference?) James Reason

2. Once upon a time . . .

3. Now: A complex system

4. Economic & political climate Top-level management decisions Line management implementation Error-producing conditions in the team and workplace Unsafe acts at sharp end Exceedances Incidents & near misses Accidents Culture Culture Cascading influences

5. Errors need to be managed at all levels of the system Everyone’s blunt end is someone else’s sharp end. (Karlene Roberts)

6. Systemic factors Social factors Individual factors Reaching ever higher for the fruit

7. Milestones • From 1917: Psychometric testing • 1940s: Cambridge Cockpit; Applied Psychology Unit; centres at Ohio State & University of Illinois; ERS (UK) • 1950s: HFS (US); ‘Human Factors in Air Transportation’ (Ross McFarland) • 1960s: Manned space flight; cockpit ergonomics; command instruments • 1970s: ALPA accident investigation course; IATA human factors committee; SHEL(L) • 1980s: CRM; ASRS; cognitive and systemic factors; interaction of many causal factors • 1990s: Organizational and cultural factors

8. Sentinel events • Tenerife runway collision • Mt Erebus and the Mahon Report • Manchester runway fire • Dryden and the Moshansky Report • BASI reports on the Monarch and Seaview accidents • NTSB Report on Embraer 120 accident at Eagle Lake, Texas (Lauber dissent) • Challenger (Vaughan) and Columbia Accident Investigation Board Report

9. Individual factors • Pilot aptitude measures • Psychomotor performance • Sensory and perceptual factors • Fatigue and stress • Vigilance decrement • Cockpit ergonomics • ‘Ironies of automation’ • Cognitive issues

10. Predictive value of WW2 AAF test battery (from Ross McFarland, 1953) Decrease in elimination rates with increase in stanine scores indicates value of properly weighted battery of tests.

11. Social and team factors • Crew resource management • LOFT and behavioural markers • Cabin evacuation studies • Maintenance teams • Air traffic controllers • Ramp workers • Naturalistic decision making • Procedural non-compliance

12. The high-hanging fruit • Targeting error traps and recurrent accidents (e.g. CFIT, maintenance omissions, etc.) • Resolving goal conflicts: production vs protection • Combating the ‘normalization of deviance’ • Striving for system resilience (high reliability) • Engineering a safe culture

13. ICAO Annex 13 (8th Ed., 1994) 1.17. Management information. Accident reports should include pertinent information concerning the organisations and their management involved in influencing the operation of the aircraft. The organisations include . . . the operator, air traffic services, airway, aerodrome and weather service agencies; and the regulatory authority. Information could include organisational structure and functions, resources, economic status, management policies and practices . . .

14. Ever-widening search forthe ‘upstream’ factors Individuals Workplace Organisation Regulators Society at large

15. Echoed in many hazardous domains Piper Alpha Challenger Young, NSW Dryden Barings Zeebrugge King’s X Chernobyl Clapham Columbia

16. CAIB Report (August, 2003) ‘In our view, the NASA organizational culture had as much to do with this accident as the foam.’ ‘When the determinations of the causal chain are limited to the technical flaw and individual failure, typically the actions taken to prevent a similar event in the future are also limited . . .’

17. But has the pendulum swung too far? Collective responsibility Individual responsibility

18. Mr Justice Moshansky onthe Dryden F-28 crash Had the system operated operated effectively, each of the (causal) factors might have been identified and corrected before it took on significance . . . this accident was the result of a failure of the air transportation system as a whole.

19. Academician Valeri Legasovon the Chernobyl disaster After being at Chernobyl, I drew the unequivocal conclusion that the Chernobyl accident was . . . the summit of all the incorrect running of the economy which had been going on in our country for many years. (pre-suicide tapes, 1988)

20. CAIB Report (Ch. 5) ‘The causal roots of the accident can be traced, in part, to the turbulent post- Cold War policy environment in which NASA functioned during most of the years between the destruction of Challenger and the loss of Columbia.’

21. Remote factors: some concerns • They have little causal specificity. • They are outside the control of system managers, and mostly intractable. • Their impact is shared by many systems. • The more exhaustive the inquiry, the more likely it is to identify remote factors. • Their presence does not discriminate between normal states and accidents; only more proximal factors do that.

22. Revisiting Poisson • Poisson counted number of kicks received by cavalrymen over a given period. • Developed a model for determining the chance probability of a low frequency/high opportunity event among people sharing equal exposure to hazard. • How many people would one expect to have 0, 1, 2, 3, 4, 5, etc. events over a given period when there is no known reason why one person should have more than any other?

23. Unequal liability: common finding No. of exceedances by fleet pilots (John Savage) More people have zero events than predicted N A few people have have more events than would be expected by chance alone 0 1 2 3 4 5 6 7 8 Number of events sustained in a given period

24. Interpreting pilot-related data • Repeated events are associated with particular conditions. Suggests the need for specific retraining. • Repeated events are not associated with particular conditions: • Bunched in a given time period. Suggests influence of local life events. Counselling? • Scattered over time. Suggests some enduring problem. Promote to management?

25. C B+ A End-of-century grades

26. Conclusions • Widening the search for error-shaping factors has brought great benefits in understanding accidents. • But maybe we are reaching the point of diminishing returns with regard to prevention. • Perhaps we should revisit the individual (the heroic as well as the hazardous acts). • History shows we did that rather well.