Who is Responsible?

Line management vs. latent errors

The second line of defense is to prevent latent errors created by line management. These managers, who implement the decisions made by upper management, are responsible for procedures, scheduling, avoiding hazards, and providing training. They are responsible to ensure that the equipment is available and reliable. The line managers are also responsible for the defects in the organization’s operating system (task, material, environment, training and the personnel).

Performance pressures

The third line of defense represents preventing errors created by high workload, undue time pressure, acceptance of hazards, and ignorance of the system. The “Dirty Dozen” defenses, 12 examples of immediate causes of human errors leading to an accident or incident, should have caught these errors but were not in place at the time. The presence of defenses or safeguards in a system usually prevent the effects of latent failures by closing the “window of opportunity” during which an active failure may be committed. These defenses include proper training, good situational awareness, and independent inspection.

Check, check, and re-check

Active failures created by the individual include:

• omission of a checklist item
• use of wrong procedures
• not following procedures
• not completing a final system check properly
• not double checking
• lack of skill and knowledge

There are defenses and countermeasures that protect us from the latent and active failures. The system can also be referred to as the organizational filters or safety nets. If the error is found or corrected because of the safety nets, then there is no accident or incident. The system worked.

Everyone plays a role in establishing the defences to latent and active errors. Management corrects or eliminates management or supervisor error (setting standards, planning, organizing, controlling and staffing). They are responsible for improving the system to ensure training, manuals, policies, procedures, and resources are available and are used. Human factors training trains personnel to use the resources and to encourage safe operations. Managers learn that a safety culture can only be fostered if line employees are provided necessary resources to do their jobs correctly. Line employees on the other hand, must be given the tools that teach them how to do their jobs without error. As an example, upper-level managers provide and control resources, such as the number of planes serviced at one time, the selection of employees to do the work, and the tools with which to perform the necessary tasks.

A safety management system requires communication of the chain of events leading to rework issues and incidents with their corrective action. A truly effective SMS program will start to eliminate latent failures. Human factors teaches employees to come up with corrective actions.