Who is Responsible?

Understanding situations that trigger errors

When we hear of an accident we frequently think, “How did that happen? That is a very safe and conscientious company.” Or sometimes we say to ourselves, “I knew that would happen. That organization was an accident waiting to happen.”

Today, many accident investigations are completed with “Reason’s Model” in mind. James Reason states that failures fall into two main categories: active failures and latent failures.

Active failures are errors and violations having immediate negative results and are usually caused by an individual. Latent failures are caused by circumstances such as scheduling problems, inadequate training, or lack of resources which results in an active failure. Investigators examine the company culture, policy, and latent errors whose effects lie dormant until triggered later by a technician. We should not just point fingers when a technician makes an error; we have to investigate the latent failure.

Reason’s Model

When we consider Reason’s Model of Error Analysis, we look at everyone’s role in preventing errors. When a company has an incident, there is a chain of events established that helps to identify the contributing human factors and the causes of the incident. Typically, latent failures existed in the regulations, management, resources, policies and company culture. Then, there were active failures from direct supervision, scheduling, use of resources, time management, and communication; as well as other active failures, such as the “Dirty Dozen,” that influenced the judgment of the technician that led to an error.

Both latent and active failures interact, creating a window for an accident to occur. Latent failures set the stage for the accident, while active failures tend to be the catalyst for the accident. As the model illustrates, there are several lines of defense, and if there is a hole in that line of defense, it can create a failure. If a situation contains a sufficient number of failures allowing the holes to line up, then an accident will occur.

Latent failures are present in the system well before an accident and are most likely bred by decision-makers, regulators, and other people far removed in time and space from the event. Conflicting goals and bad management decisions unknowingly create the conditions under which the latentfailures can reveal themselves. Safety efforts should be directed at discovering and solving these latent failures rather than by localizing efforts to minimize active failures by the technician. This is why with any human factors program, management has to be involved right from the beginning.

First line of defense

The first line of defense in preventing incidents is the management of an organization, the decision-makers. Upper management and the regulatory authorities are responsible for setting goals and for managing available resources to achieve safety and cost-effective transportation. The owners are responsible to ensure the presence of qualified individuals to accomplish the task. Some regulatory authorities actually contribute to the existence of latent failures because of lack of regulations or clarity of them. Transport Canada and EASA both have regulations and subject requirement for human factors training in the maintenance department. However, the FAA has yet to regulate human factors subject matter or time requirements.

Creating defenses against the establishment of latent errors within a company should include effective policies and procedures, continuous training, and a confidential reporting program to alert managers to the presence of hazards or deficiencies. The company must have a clear Safety Management System in place which requires the CEO to provide guiding actions throughout the organization. Those in top positions must foster a climate in which there is a positive attitude towards comments and feedback from lower levels of the organization. Everyone’s role is to be well trained and educated in understanding the consequences and prevention of an unsafe act created by human error.

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