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HFG Conference, RAeS, 15 October 2003. Error Management: Achievements and Challenges (Have we made a difference?). James Reason. Once upon a time . . . Now: A complex system. Economic & political climate Top-level management decisions Line management implementation

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cascading influences

Economic & political climate

Top-level management decisions

Line management implementation

Error-producing conditions in the team and workplace

Unsafe acts at sharp end


Incidents & near misses




Cascading influences
errors need to be managed at all levels of the system
Errors need to be managed at all levels of the system

Everyone’s blunt end is someone

else’s sharp end.

(Karlene Roberts)

  • 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
sentinel events
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
individual factors
Individual factors
  • Pilot aptitude measures
  • Psychomotor performance
  • Sensory and perceptual factors
  • Fatigue and stress
  • Vigilance decrement
  • Cockpit ergonomics
  • ‘Ironies of automation’
  • Cognitive issues
predictive value of ww2 aaf test battery from ross mcfarland 1953
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.

social and team factors
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
the high hanging fruit
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
icao annex 13 8 th ed 1994
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 . . .

ever widening search for the upstream factors
Ever-widening search forthe ‘upstream’ factors





Society at large

echoed in many hazardous domains
Echoed in many hazardous domains

Piper Alpha


Young, NSW




King’s X




caib report august 2003
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 . . .’

but has the pendulum swung too far
But has the pendulum swung too far?





mr justice moshansky on the dryden f 28 crash
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


academician valeri legasov on the chernobyl disaster
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)

caib report ch 5
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.’

remote factors some concerns
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.
revisiting poisson
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?
unequal liability common finding
Unequal liability: common finding

No. of exceedances by fleet pilots (John Savage)

More people

have zero events

than predicted


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

interpreting pilot related data
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?
  • 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.