In my last article I outlined how using a simplistic root-causal analysis often results in superficial findings that miss the actual causes of an accident. These superficial investigations typically find that the accident is the fault of a front-line employee. This is very convenient for the various powerful interests as they can escape liability. Unfortunately, blaming a front-line employee does little to prevent another accident in the future.
Recently, I was interviewed for a story about some mishaps that have occurred when minor children were flying on their own. It is not uncommon for children to be flying without an adult, with scenarios ranging from divorced parents to traveling to visit relatives. Known in the airline industry as unaccompanied minors, airlines have policies and procedures in place to ensure the children traveling on their own are safe and secure.
Unfortunately, sometimes things do not work as intended, and in one case a 6-year-old was sent to the wrong airport after a connection. Fortunately, all turned out well for what was bound to have been a traumatic experience for the families.
A few days later it was reported that the employee involved in the case is no longer working for the airline. I do not think any of us would be surprised if they did this to try to mitigate any legal damages from the fallout of this debacle.
Does anyone believe that removing the employee will prevent this from happening in the future? There are only two possibilities for what went wrong here. One, the unlikely scenario that the employee intentionally put the child on the wrong flight. If that was the case, then obviously the employee should be removed from the job, but we should still examine what broke down in the system that enabled such an employee to be hired. We would also want to investigate how the policies and procedures would even allow a single point of failure in this case.
The second, more probable scenario, is that something broke down in the airline’s policies and procedures as designed – with everyone trying to do the right thing. If this is what happened, then the fault should lie entirely with the airline. There should have been at least two people ensuring the correct flight, plus a computer confirmation as the child boarded the flight, and again, cabin crew again confirming it. That would seem the bare minimum anyone would expect. Either way, the fault here would be in the policies and procedures, and here the airline should not be shielded from culpability by firing an employee.
Still, we see the termination of employees as a common defense. The idea that accidents are caused by “bad apples,” so we can eliminate them by just firing those types of people has been around for about 100 years. Perhaps longer. We see it often in the medical industry, where the faulty system design opens the door to catastrophic outcomes, but the blame is placed on those with the least control over the system safety design – people like nurses or other lower ranking employees.
Blaming a lower ranking employee is not unique to airlines or hospitals. A driver of a big rig might be blamed for an accident that was the result of a combination of organizational pressures, or even questionable design of software systems designed to make driving “easier.” Payment incentives can result in drivers pushing themselves to longer hours, costs can result in drivers trying to rest in vehicles not designed for rest.
We have seen pilots operate with insufficient sleep due to the costs of local accommodations, choosing to sleep in a chair overnight. Couple this with so-called driver-assist systems that have exaggerated their capabilities, touted with names such as “autopilots,” and we have a recipe for disaster.
There are powerful incentives involved. Organizations want to shield executives as well as their “star” employees, such as highly ranked medical doctors – the very people who have actual control over how the policies and procedures are designed, or what technology to purchase and how that technology is trained and implemented. It all comes down to the design of the socio-technical system itself, but few investigators are trained in how to identify these systemic aspects.
System theory provides a powerful way to understand all the factors, from driver decisions, the rules implemented by their employer, the regulatory framework and the way the “autopilot” functions, how it was designed and how it interacts with the users. As I stated in my last article, System Theoretic Accident Models and Processes (STAMP) provides the only validated way using system theory to fully understand the socio-technical factors in an accident. It is only through fully understanding an accident can we design controls to prevent a future one.
