THE HUMAN ERROR
REGARDLESS OF YOUR ACTION, IF YOU REPORT YOUR ERROR AND ASSIST IN ITS PREVENTION, NO DISCIPLINARY ACTION WILL BE TAKEN
THE ERA OF THE “NO BLAME” CULTURE This enables an organization to learn from the error and root causes to be found. It lessens the chances of a repeat error being made. The data helps find trends and system causes. However, it interferes with one’s sense of justice — i.e., that feeling that he/she “just got away with murder.” (Coming to work drunk and driving the service truck into the side of an aircraft is OK?) It makes no provision for reckless behavior. A form of this just culture is a must for a successful SMS.
ALL ERRORS MUST BE REPORTED AND WILL BE TREATED AS “LEARNING OUTCOMES” EXCEPT IN CASES OF RECKLESS ERROR
WHAT IS A JUST CULTURE? It is where everyone feels that the guilty party was treated fairly and justly after they made a human error or reported a near miss.
It clearly spells out that all errors will be treated as learning outcomes and — except for cases of reckless behavior — no discipline will be administered.
It is a win-win situation and is the foundation of any successful SMS.
WHAT IS AN ADMINISTRATIVE POLICY? An administrative policy is one that spells out exactly
how an error or reported near miss will be handled. It will inform all exactly where that line in the sand is when it comes to discipline. The administraton of discipline will become a small part of the overall policy. The policy is based the following suppositions: a) Errors are not made on purpose (if they were, it would be sabotage);
b) The person making the error is the least likely to ever make it again;
c) Disciplining a person usually does nothing positive to reduce a repeat of the error if it was not intentional;
d) The policy will become the heart of your SMS. It has been determined that discipline will not be
required to help prevent a repeat of the error 95 to 97 percent of the time. Based on work done by David Marx, the father of just
culture, the following are the three types of error that must be dealt with.
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1. NORMAL ERROR - NO CULPABILITY = LEARNING OUTCOME (CONSOLE)
Normal errors are the result of being human and/or the system in which the person works. It is the unintentional forgetting to do something or doing something wrong while thinking it was right. There is no intention to make the error. You might later think to yourself, “How could I have been so stupid?” Maybe you forget to replace the oil cap after checking the oil level, or install a component wrong because you have never had the training (system er- ror) and the manual is ambiguous but it seems right. The end result is a learning outcome in which the
knowledge gained is used to devise ways to prevent it from recurring to anyone. About 80 percent of all errors will fall into this category.
2. AT-RISK ERROR - NO CULPABILITY (THIS TIME) = LEARNING OUTCOME (COACH)
At-risk errors are the result of the person knowing what he/she is doing is wrong but seeing no bad outcomes and often positive rewards for the action. The key is that the person fails to see or realize the risk in what they are doing. Norms (the way we do things around here) often result in an at-risk error.
Remember last month’s Mickey Mouse and Donald
Duck “pencil whipping” for the tire pressures on the DC8s? That was a norm that ultimately resulted in the loss of 261 lives. Because the people were not aware of the risk in what they were doing, they would receive one “get out of jail free” card and be coached to realize the danger or risk. Should the person repeat the error when they realize the risk, the error falls into the reckless error category. The classic norm that was at risk has to be American Airlines DC-10 Flight 191 out of Chicago that lost the No. 1 engine on takeoff. Two hundred and seventy three people died as a result of maintenance using a forklift to remove and reinstall the wing-mounted engines with the pylon attached, instead of separating the engine from the pylon before removing the pylon. This was an at-risk error as what they were doing was a violation. They failed to see the risk but had the positive reward of saving 22 man hours per engine. To my knowledge, nobody was ever charged (disciplined) for this at-risk error.
3. RECKLESS ERROR - CULPABLE = LEARNING OUT- COME (DISCIPLINE)
Reckless error results from an action that the person knows has a significant and unjustifiable risk but they choose to do it anyway, consciously disregarding the possible consequences. The best example of this is the drunk who chooses to drive. The person knows the risk but chooses to do it anyway. An aviation example would be the maintenance person who real- izes he forgot his flashlight up behind the instrument panel and decides to say nothing. There can still be a learning outcome as to why the person chose to take that risk but discipline might be required to ensure that it does not happen again.
DOMmagazine
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