For those who subscribe to James Reason paradigm, was this a maintenance error or wilfull violation?
SKYbrary - Human Factors Analysis and Classification System (HFACS)
Errors
- Skill-Based Errors: Errors which occur in the operator’s execution of a routine, highly practiced task relating to procedure, training or proficiency and result in an unsafe situation (e.g., fail to prioritize attention, checklist error, negative habit).
- Decision Errors: Errors which occur when the behaviors or actions of the operators proceed as intended yet the chosen plan proves inadequate to achieve the desired end-state and results in an unsafe situation (e.g, exceeded ability, rule-based error, inappropriate procedure).
- Perceptual Errors: Errors which occur when an operator's sensory input is degraded and a decision is made based upon faulty information.
Violations
- Routine Violations: Violations which are a habitual action on the part of the operator and are tolerated by the governing authority.
- Exceptional Violations: Violations which are an isolated departure from authority, neither typical of the individual nor condoned by management.