THE HUMAN ERROR


Why Don’t We Just Follow the Rules?


By Gordon Dupont, System Safety Services


BREAKING RULES AT WORK Rule breaking at work goes along the same lines — no negative consequences and at least one positive conse- quence.


Let me give you a true example that involved yours I


read with great interest Patrick Kinane’s article in Just Plane Culture in the November/December issue of D.O.M. magazine — partly because the words “Dirty


Dozen” were mentioned but mostly because it is a great article on “looking past the man” to find the root causes. Please note that the Dirty Dozen are contributing factors and NOT root causes. They are so very important because as we said in my first article, “they train the person on how to avoid the error they don’t ever intend to make.” I agree with Patrick 100 percent and look to safety management systems (SMS) to guide a company’s culture towards what Patrick is advocating. There is an old saying: “Rules are made to be broken.” Those who follow this philosophy soon end up in grief, yet we all have broken the odd rule from time to time. Some might have been inadvertent while others might have been a willful violation. Let’s look at the most common rule broken every day


all around the world: the speed limit. If someone tells me that he/she has never broken a rule, they are either a saint or a liar and I would suspect the latter. If the speed limit sign says 50 mph, then it doesn’t mean 51 or 52 or higher. However, the average driver will be between five and 10 mph over the speed limit unless the weather is bad, there is a police officer close by or your mother-in- law is in the car with you. Why do we do it? While some us might think that our


above-average driving skills preclude us from having to follow the rule (tell that one to the judge), the answer is actually very simple. We foresee no negative consequences in doing so and the positive consequence of getting home sooner serves to justify the rule breaking.


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truly years ago. I started work for a company that had a lot of DC8s that were getting “long in the tooth” (between 40,000 and 50,000 hard-worked hours). Thus, they were getting to be high-maintenance aircraft. The ramp crew I joined had the reputation of always getting their aircraft out on time for which there were a lot of “atta-boys”. However, to accomplish this there were times on midnight shift when some things had to be “deferred” in order to make the timeline. By “deferred,” I mean less important things were “signed off” (OK, pencil-whipped) and caught the next night. I felt that I was a professional and would never sign for something I had not done. Not a problem, just initial “MM” for Mickey Mouse or “DD”for Donald Duck. Now, this didn’t happen often, but when there were more snags than could be cleared in the time we had, “MM” or “DD” signed out the time-consuming tire pressure checks. After all, how often do you check your car tire pressures?


What’s the big deal? The aircraft left on time, which was the positive consequence, and there were no negative consequences that I or my fellow crew could foresee. You can go to our Web site at www.system-safety. com, click on Safety Videos and open and read the case study of “Death of an Airline.” That is a negative consequence for which I could have been responsible. That is also why that was the first training video I produced. The picture you see is of the accident DC8 with what is left of 261 people scattered in it. A blown up picture of this hangs on my office wall as a reminder of what a simple human error can do. Just one tire with low pressure and 261 people paid the ultimate price. But it did leave on time. Had that occurred at our home base after “MM” had signed for the tire pressures, just how many “atta-boys” would have been handed out? Criminal negligence causing death comes to mind, but no court could ever punish me


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