Is this human error?


James Reason would classify this as a violation rather than error

Reason’s violations come in two flavours, ‘routine’ violations which are accepted by the organisation, for example relying on a memorised checklist rather than the paper one, and exceptional violations, such as failing to carry out a takeoff checklist at all. Note that ‘exceptional’ means that they are not typical of the individual or condoned by the organisation.

But procedural compliance (a great word) is enforced by organisations so this is where we get into the cultural and organisational aspects of human behaviour. Back in the day the RAAF was much more tolerant of such behaviour. So would this be routine or exceptional? That depends in part on the response of the organisation, was the pilot disciplined, or did he get a slap on the wrist? Was this a pattern of behaviour for that pilot or more broadly among others, i.e representative of a local culture of normalised deviance.

Now I’m not sure who it was that first stated the principle, but the enforcement of procedure (e.g. compliance) is the classic role of middle management, and when compliance is a rare and wonderful thing, look to a failure of that same middle management. If you want to know more about how the decay of an organisations culture can enable this sort of behaviour, and what that leads to, check out the the tragic story of Bud Holland and Czar 52.