HOW DO YOU TELL THE DIFFERENCE? You will need to answer the following questions.
1. Was the act deliberate with a reasonable knowledge of the consequences? Yes = reckless
2. Has the person made similar errors in the past? Yes = reckless 3. Do they accept responsibility for their actions? Yes = likely at risk 4. Has the person learned from the experience? Yes = likely at risk 5. Are they likely to do it again? Yes = reckless
The only purpose of discipline has to be to ensure that it does not happen again. There will be those who will have trouble agreeing with this culture change and will hide behind the “he/she must be held accountable” adage. These are the remnants of the blame (cement boot) culture. This is especially true of the at-risk error wherein the error was made knowingly but the possible consequences weren’t. At-risk errors only occur about 15 percent of the time, leaving reckless errors with the outcome of discipline responsible for only five percent. Who would have ever thought it would be that low? In a truly just culture it will be and the cement boots will be a thing of the past. In the next article I’ll start discussing the “Dirty Dozen,” starting with No. 12,
norms, as it ties in with my last few articles. Please send any comments good, bad or even down-right ugly that you wish, as I am open to discussing any human error topic that you feel is important.
Gordon Dupont worked as a special programs coordinator for Transport Canada from March 1993 to August 1999. He was responsible for coordinating with the aviation industry in the development of programs that would serve to reduce maintenance error. He assisted in the development of Human Performance in Maintenance (HPIM) Parts 1 and 2. The “Dirty Dozen” maintenance safety posters were an outcome of HPIM Part 1.
Prior to working for Transport, Dupont worked for seven years as a technical investigator for the Canadian Aviation Safety Board (later to become the Canadian Transportation Safety Board). He saw firsthand the tragic results of maintenance and human error.
Dupont has been an aircraft maintenance engineer and commercial pilot in Canada, the United States and Australia. He is the past president and founding member of the Pacific Aircraft Maintenance Engineers Association. He is a founding member and a board member of the Maintenance And Ramp Safety Society (MARSS).
Dupont, who is often called “The Father of the Dirty Dozen,” has provided human factors training around the world. He retired from Transport Canada in 1999 and is now a private consultant. He is interested in any work that will serve to make our industry safer. Visit www.
system-safety.com for more information.
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