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Local rationality
What is striking about many accidents in complex systems is that people were doing exactly the sorts of things they would usually be doing—the things that usually lead to success and safety. Mishaps are more typically the result of everyday influences on everyday decision making than that they are isolated cases of erratic individuals behaving unrepresentatively (e.g. Woods et al., 1994; Reason, 1997; AMA, 1998; Sanne, 1999). People are doing what makes sense given the situational indications, operational pressures and organizational norms existing at the time. Accidents are seldom preceded by bizarre behavior. People's errors and mistakes (such as there are in any objective sense) are systematically coupled to their circumstances and tools and tasks. Indeed, a most important empirical regularity of human factors research since the mid-forties is the local rationality principle. What people do makes sense to them at the time—it has to, otherwise they would not do it. People do not come to work to do a bad job; they are not out on crashing cars or airplanes or grounding ships. The local rationality principle, originating in Simon (1969), says that people do things that are reasonable, or rational, based on their limited knowledge, goals, and understanding of the situation and their limited resources at the time (Woods et al., 1994). Avoiding the mechanisms of the hindsight bias means acknowledging that failures are baked into the nature of people's work and organization; that they are symptoms of deeper trouble or by-products of systemic brittleness in the way business is done. It means having to find out why what people did back there and then actually made sense given the organization and operation that surrounded them.
To explain outcome failure, we need to convert the search for human failures into a search for human sensemaking (Snook, 2000). The question is not "where did people go wrong?", but "why did this assessment or action make sense to them at the time?". Such real insight is derived not from judging people from the position of retrospective outsider, but from seeing the world through the eyes of the protagonists at the time. When looking at the sequence of events from this perspective, a very different story often struggles into view.
The reconstruction of unfolding mindset
How do we capture the perspective from inside the tunnel, so that we can generate meaningful results from our probe? The investigator is confronted by a problem similar to that of the field researcher—how to migrate from a context-specific set of data to more concept-based results that are interpretable and falsifiable; that are more than just another anecdote (Woods, 1993; Xiao & Vincente, 2000). Falsifiability means the investigator has to leave a trace that others can follow. In human factors it is not uncommon to make the shift from context-specific to concept-dependent in one big leap (e.g. "this underestimate of the closing rate signifies a loss of situation awareness"); which produces conclusions that no one else can verify. The challenge is to build up an account that moves from the context-specific to the concept-dependent gradually, leaving a clear trace for others to follow, verify, and debate (e.g. Hollnagel et al., 1981). To be sure, any explanation of past performance that we arrive at remains a fictional story; an approximation; a tentative match—open to revision as new evidence may come in. In the words of Woods (1993, p. 238): "A critical factor is identifying and resolving all anomalies in a potential interpretation. We have more confidence in, or are more willing to pretend that, the story may in fact have some relation to reality if all currently known data about the sequence of events and background are coherently accounted for by the reconstruction". Below I present five steps by which the investigator could begin to reconstruct a concept-dependent account from context-specific incident data.
1. Laying out the sequence of events in context-specific language
The record and other data about an incident typically reveals a sequence of activities—human observations, actions, assessments, decisions; as well as changes in the state of the process or system. This sequence of events forms the starting point for an examination of the inside of the tunnel. The goal is to examine how people's mindset unfolded in parallel with the situation evolving around them, and how people, in turn, helped influence the course of events. There is a fundamental reciprocity in human information processing (Neisser, 1976; Clark, 1997) from which the investigator can benefit by triangulation and interpolation. Cues and indications from the world influence people's situation assessments, which in turn inform their actions, which, in turn, change the world and what it reveals about itself, and so forth. This means that if certain actions or assessments are difficult to interpret, then the circumstances (and particularly what was observable about them) in which they appeared can hold the key to their sensibility. Indeed, the reconstruction of mindset often begins not with the mind, but with the situation in which the mind found itself. Similarly, if there is a lack of data from system or process sources, certain behaviors that are canonical in particular process states can help you reconstruct the state of cues and indications observable at the time. This makes that there are various entries to scour the record for events and activities:
• Shifts in behavior. There can be points where people may have realized that the situation was different from what they believed it to be previously. You can see this either in their remarks or their actions. These shifts are markers where later you want to look for the indications unfolding around them that people may have used to come to a different realization.
• Actions to influence the process may come from people's own intentions. Depending on the kind of data that the domain records or provides, evidence for these actions may not be found in the actions themselves, but in process changes that follow from them. As a clue for a later step, such actions also form a nice little window on people's understanding of the situation at that time.
• Changes in the process. Any significant change in the process that people manage must serve as event. Not all changes in a process managed by people actually come from people. In fact, increasing automation in a variety of workplaces has led to the potential for autonomous process changes almost everywhere—for example:
• Automatic shut-down sequences or other interventions;
• Alarms that go off because a parameter crossed a threshold;
• Uncommanded mode changes;
• Autonomous recovery from undesirable states or configurations.
Yet even if they are autonomous, these process changes do not happen in a vacuum. They always point to human behavior around them; behavior that preceded it and behavior that followed it. People may have helped to get the process into a configuration where autonomous changes were triggered. And when changes happen, people notice them or not; people respond to them or not. Such actions, or the lack of them, again give you a strong clue about people's knowledge and current understanding.
The way to capture these events and activities during this stage is in context-specific language—meaning a minimum of psychological diction; instead a version of what happened in terms that domain people use to talk about their own work. The goal is to miss as few details as possible. Skipping to higher-level descriptions of human performance is seductive, even at this stage, but should be avoided. Seemingly low-level concepts, such as "decision making" or "diagnosis", already are large—meaning they contain a lot of behavior—and are easily mistaken for detailed insight into psychological issues (Woods, 1993; Hollnagel, 1998).
Time (and/or space) can be powerful organizing principles to help lay out the activities and events. Behavior, and the process in which it took place, unfolded over time and, probably, in some space. By organizing data spatially and temporally (e.g. through drawing maps or timelines or both), actions and assessments can become more clearly coupled to the process state and location in which they took place; they can recover their spot in the flow of events of which they were part and which helped bring them forth. Such organization likely yields further clues about why actions and assessments made sense to people back there and then.
2. Divide the sequence of events into episodes, if necessary
Accidents do not just happen; they evolve over a period of time. Sometimes this time may be long (e.g. 34 hours, see NTSB, 1996), and where it is, it may be fruitful to divide the sequence of events into separate episodes that each deserve their own further human performance analysis. Cues about where to chunk up the sequence of events can mostly come from the domain description arrived at above, especially at discontinuities in human assessments or actions or process states.
There is of course inherent difficulty in deciding what counts as the overall beginning of a sequence of events (especially the beginning—the end often speaks for itself). Since, philosophically, there is no such thing as a root cause, there is technically no such thing as the beginning of a mishap. Yet the investigation needs to start somewhere. Making clear where it starts and explaining this choice is a good step toward a structured, well-engineered human performance investigation. Here is one option: Take as the beginning of your first episode the first assessment, decision or action by people or the system close to the mishap—the one that, according to you, set the sequence of events in motion. This assessment or action can be seen as a trigger for the events that unfold from there. Of course the trigger itself has a reason, a background, that extends back beyond the mishap sequence—both in time and in place. The whole point of taking a proximal action or event as starting point is not to ignore this background, but to identify concrete points to begin the investigation into them.
3. Find out how the world looked or changed during each episode
This step is about reconstructing the unfolding world that people inhabited: find out what their process was doing; what data was available. This is the first step toward coupling behavior and situation—toward putting the observed behavior back into the situation that produced and accompanied it. Laying out how some of the critical parameters changed over time is nothing new to investigations. Many accident report appendices contain read-outs from data recorders, which show the graphs of known and relevant process parameters. But building these pictures is often where investigations stop today. Tentative references about connections between known parameters and people's assessments and actions are sometimes made, but never in a systematic, or graphic way. The point here to marry all the events that have been identified with the unfolding process—to begin to see the two in parallel, as an inextricable, causal dance-a-deux. The point of step three is to build a picture that shows these connections.
The record will most likely contain (some kind of) data about how process parameters were changing over time (speed until impact, for example, but also traces of changing pressures, ratios, settings, quantities, automation or computer modes, rates, and so forth) and how these were presented to the people in question. Considerable domain knowledge (either from the investigator him/herself or from outside) may be necessary to determine which of the parameters could have counted as a stimulus for the behavior under investigation. The difficulty (reflected in the next step) will be to move from merely showing that certain data was physically available, to arguing which of these data was actually observable and made a difference in people's assessments and actions—and why this made sense to them back then.
4. Identify people's goals, focus of attention and knowledge active at the time
So what, out of all the data available, did people actually see and how did they interpret it? Given that human behavior is goal-directed and governed by knowledge activated in situ (Woods et al., 1994), clues are available from looking at people's goals at the time, and at the knowledge activated to help pursue them.
Finding what goals people were working on does not need to be difficult. It often connects directly to how the process was unfolding around them:
• What was canonical, or normal at this time in the operation? Tasks (and the goals they represent) relate in systematic ways to stages in a process.
• What was happening in the process managed by the people? Systems were set or inputs were made—changes which connect to the tasks people were carrying out.
• What were other people in the operating environment doing? People who work together on common goals often divide the necessary tasks among them in predictable or complementary ways. There may be standard role divisions, for example between pilot flying and pilot not-flying, that specify the work for each.
It is seldom the case, however, that just one goal governs what people do. Most complex work is characterized by multiple goals, all of which are active or must be pursued at the same time (on-time performance and safety, for example). Depending on the circumstances, some of these goals may be at odds with one another, producing goal conflicts. Any analysis of human performance has to take the potential for goal conflicts into account. Goal trade-offs can be generated by the nature of the work itself. For example, anesthesiologists need to maximize pre-operative workup time with a patient to guard patient safety and quell liability concerns, while their schedules interlock with other professions that exercise pressure with respect to e.g. timing. Goal conflicts can also precipitate from the organizational level. In this case, not all goals (or their respective priorities) are written down in guidance or procedures or job descriptions. In fact, most are probably not. This makes it difficult to trace or prove their contribution to particular assessments or actions. However, previous occurrences in similar circumstances or in the same organization may yield powerful clues. They can substantially influence people's criterion setting with respect to a goal conflict. For example, a decision to take off or not to take off in bad weather may be precluded by earlier incidents, or, conversely, encouraged by organizational reactions to lack of on-time performance.
When it comes to knowledge, not all knowledge people once showed to possess is necessarily available when called for. In fact, the problem of knowledge organization (is it structured so that it can be applied effectively in operational circumstances?) and inert knowledge (even if it is there, does it get activated in context?) should attune investigators to mismatches between how knowledge was acquired and how it is to be applied in practice. For example, if material is learned in neat chunks and static ways (books, most computer-based training) but needs to be applied in dynamic situations that call for novel and complex combinations, then inert knowledge is a risk (Woods et al., 1994).
What people know and what they try to accomplish jointly determines where they will look; where they will direct their attention—and consequently, which data will be observable to them. Recognize how this is, once again, the local rationality principle. People are not unlimited cognitive processors (there are no unlimited cognitive processors in the entire universe). People do not know and see everything all the time. So their rationality is limited, or bounded. What people do, where they focus, and how they interpret cues makes sense from their point of view; their knowledge, their objectives and their limited resources (e.g. time, processing capacity, workload). Re-establishing people's local rationality will help you understand the gap between data availability and what people actually saw or used. In dynamic situations, people direct their attention as a joint result of:
• What their current understanding of the situation is, which in turn is determined partly by their knowledge and goals. Current understanding helps people form expectations about what should happen next (either as a result of their own actions or as a result of changes in the world itself).
• What happens in the world. Particularly salient or intrusive cues will draw attention even if they fall outside people's current interpretation of what is going on.
Keeping up with a dynamic world, in which situations evolve and change, is a demanding part of much operational work, and implies two different kinds of "errors". People may fall behind during rapidly changing conditions, and update their interpretation of what is happening constantly, trying to follow every little change in the world. Or people may become locked in one interpretation, even while evidence around them suggests that the situation has changed (see De Keyser & Woods, 1990).
5. Step up to a conceptual description
The goal here is to build an account of human performance that runs parallel to the one created in step 1. This time, however, the language that describes the same sequence of events is not one of domain terms, it is one of human factors or psychological concepts. One reason for the importance of this step perhaps goes beyond the mandate of an individual investigation. Getting away from the context-specific details—in a language that may not communicate well with other context-specific sequences of events—opens a crucial way to learn from failure: discovering similarities between seemingly disparate events. When people instead stress the differences between sequences of events, learning anything of value beyond the one event becomes difficult (Rochlin, 1999). Similarities between accounts of different occurrences can point you to common conditions that helped produce the problem under investigation. Figure 2 shows the steps involved in the reconstruction of unfolding mindset.
Conclusion
The systematic investigation of human contributions to accidents is not yet a very well-established practice with common methods or assumptions. Investigators are often forced to rely almost exclusively on domain knowledge and common sense, but this exposes them to the mechanisms of hindsight. Human performance evidence can get disembodied from the flow of events that accompanied it and brought it forth; and conclusions about the human contribution easily become counterfactual and judgmental—stressing what people should have done to avoid the accident, but failed to do. None of this explains what really happened or why. There may be a need for stronger appreciation among investigators of the methodical challenges and pitfalls associated with retrospective analyses of human performance. Even clearer is the need for further development of ways in which investigators can systematically reconstruct the human contribution to accidents and avoid the biases of hindsight.
What is striking about many accidents in complex systems is that people were doing exactly the sorts of things they would usually be doing—the things that usually lead to success and safety. Mishaps are more typically the result of everyday influences on everyday decision making than that they are isolated cases of erratic individuals behaving unrepresentatively (e.g. Woods et al., 1994; Reason, 1997; AMA, 1998; Sanne, 1999). People are doing what makes sense given the situational indications, operational pressures and organizational norms existing at the time. Accidents are seldom preceded by bizarre behavior. People's errors and mistakes (such as there are in any objective sense) are systematically coupled to their circumstances and tools and tasks. Indeed, a most important empirical regularity of human factors research since the mid-forties is the local rationality principle. What people do makes sense to them at the time—it has to, otherwise they would not do it. People do not come to work to do a bad job; they are not out on crashing cars or airplanes or grounding ships. The local rationality principle, originating in Simon (1969), says that people do things that are reasonable, or rational, based on their limited knowledge, goals, and understanding of the situation and their limited resources at the time (Woods et al., 1994). Avoiding the mechanisms of the hindsight bias means acknowledging that failures are baked into the nature of people's work and organization; that they are symptoms of deeper trouble or by-products of systemic brittleness in the way business is done. It means having to find out why what people did back there and then actually made sense given the organization and operation that surrounded them.
To explain outcome failure, we need to convert the search for human failures into a search for human sensemaking (Snook, 2000). The question is not "where did people go wrong?", but "why did this assessment or action make sense to them at the time?". Such real insight is derived not from judging people from the position of retrospective outsider, but from seeing the world through the eyes of the protagonists at the time. When looking at the sequence of events from this perspective, a very different story often struggles into view.
The reconstruction of unfolding mindset
How do we capture the perspective from inside the tunnel, so that we can generate meaningful results from our probe? The investigator is confronted by a problem similar to that of the field researcher—how to migrate from a context-specific set of data to more concept-based results that are interpretable and falsifiable; that are more than just another anecdote (Woods, 1993; Xiao & Vincente, 2000). Falsifiability means the investigator has to leave a trace that others can follow. In human factors it is not uncommon to make the shift from context-specific to concept-dependent in one big leap (e.g. "this underestimate of the closing rate signifies a loss of situation awareness"); which produces conclusions that no one else can verify. The challenge is to build up an account that moves from the context-specific to the concept-dependent gradually, leaving a clear trace for others to follow, verify, and debate (e.g. Hollnagel et al., 1981). To be sure, any explanation of past performance that we arrive at remains a fictional story; an approximation; a tentative match—open to revision as new evidence may come in. In the words of Woods (1993, p. 238): "A critical factor is identifying and resolving all anomalies in a potential interpretation. We have more confidence in, or are more willing to pretend that, the story may in fact have some relation to reality if all currently known data about the sequence of events and background are coherently accounted for by the reconstruction". Below I present five steps by which the investigator could begin to reconstruct a concept-dependent account from context-specific incident data.
1. Laying out the sequence of events in context-specific language
The record and other data about an incident typically reveals a sequence of activities—human observations, actions, assessments, decisions; as well as changes in the state of the process or system. This sequence of events forms the starting point for an examination of the inside of the tunnel. The goal is to examine how people's mindset unfolded in parallel with the situation evolving around them, and how people, in turn, helped influence the course of events. There is a fundamental reciprocity in human information processing (Neisser, 1976; Clark, 1997) from which the investigator can benefit by triangulation and interpolation. Cues and indications from the world influence people's situation assessments, which in turn inform their actions, which, in turn, change the world and what it reveals about itself, and so forth. This means that if certain actions or assessments are difficult to interpret, then the circumstances (and particularly what was observable about them) in which they appeared can hold the key to their sensibility. Indeed, the reconstruction of mindset often begins not with the mind, but with the situation in which the mind found itself. Similarly, if there is a lack of data from system or process sources, certain behaviors that are canonical in particular process states can help you reconstruct the state of cues and indications observable at the time. This makes that there are various entries to scour the record for events and activities:
• Shifts in behavior. There can be points where people may have realized that the situation was different from what they believed it to be previously. You can see this either in their remarks or their actions. These shifts are markers where later you want to look for the indications unfolding around them that people may have used to come to a different realization.
• Actions to influence the process may come from people's own intentions. Depending on the kind of data that the domain records or provides, evidence for these actions may not be found in the actions themselves, but in process changes that follow from them. As a clue for a later step, such actions also form a nice little window on people's understanding of the situation at that time.
• Changes in the process. Any significant change in the process that people manage must serve as event. Not all changes in a process managed by people actually come from people. In fact, increasing automation in a variety of workplaces has led to the potential for autonomous process changes almost everywhere—for example:
• Automatic shut-down sequences or other interventions;
• Alarms that go off because a parameter crossed a threshold;
• Uncommanded mode changes;
• Autonomous recovery from undesirable states or configurations.
Yet even if they are autonomous, these process changes do not happen in a vacuum. They always point to human behavior around them; behavior that preceded it and behavior that followed it. People may have helped to get the process into a configuration where autonomous changes were triggered. And when changes happen, people notice them or not; people respond to them or not. Such actions, or the lack of them, again give you a strong clue about people's knowledge and current understanding.
The way to capture these events and activities during this stage is in context-specific language—meaning a minimum of psychological diction; instead a version of what happened in terms that domain people use to talk about their own work. The goal is to miss as few details as possible. Skipping to higher-level descriptions of human performance is seductive, even at this stage, but should be avoided. Seemingly low-level concepts, such as "decision making" or "diagnosis", already are large—meaning they contain a lot of behavior—and are easily mistaken for detailed insight into psychological issues (Woods, 1993; Hollnagel, 1998).
Time (and/or space) can be powerful organizing principles to help lay out the activities and events. Behavior, and the process in which it took place, unfolded over time and, probably, in some space. By organizing data spatially and temporally (e.g. through drawing maps or timelines or both), actions and assessments can become more clearly coupled to the process state and location in which they took place; they can recover their spot in the flow of events of which they were part and which helped bring them forth. Such organization likely yields further clues about why actions and assessments made sense to people back there and then.
2. Divide the sequence of events into episodes, if necessary
Accidents do not just happen; they evolve over a period of time. Sometimes this time may be long (e.g. 34 hours, see NTSB, 1996), and where it is, it may be fruitful to divide the sequence of events into separate episodes that each deserve their own further human performance analysis. Cues about where to chunk up the sequence of events can mostly come from the domain description arrived at above, especially at discontinuities in human assessments or actions or process states.
There is of course inherent difficulty in deciding what counts as the overall beginning of a sequence of events (especially the beginning—the end often speaks for itself). Since, philosophically, there is no such thing as a root cause, there is technically no such thing as the beginning of a mishap. Yet the investigation needs to start somewhere. Making clear where it starts and explaining this choice is a good step toward a structured, well-engineered human performance investigation. Here is one option: Take as the beginning of your first episode the first assessment, decision or action by people or the system close to the mishap—the one that, according to you, set the sequence of events in motion. This assessment or action can be seen as a trigger for the events that unfold from there. Of course the trigger itself has a reason, a background, that extends back beyond the mishap sequence—both in time and in place. The whole point of taking a proximal action or event as starting point is not to ignore this background, but to identify concrete points to begin the investigation into them.
3. Find out how the world looked or changed during each episode
This step is about reconstructing the unfolding world that people inhabited: find out what their process was doing; what data was available. This is the first step toward coupling behavior and situation—toward putting the observed behavior back into the situation that produced and accompanied it. Laying out how some of the critical parameters changed over time is nothing new to investigations. Many accident report appendices contain read-outs from data recorders, which show the graphs of known and relevant process parameters. But building these pictures is often where investigations stop today. Tentative references about connections between known parameters and people's assessments and actions are sometimes made, but never in a systematic, or graphic way. The point here to marry all the events that have been identified with the unfolding process—to begin to see the two in parallel, as an inextricable, causal dance-a-deux. The point of step three is to build a picture that shows these connections.
The record will most likely contain (some kind of) data about how process parameters were changing over time (speed until impact, for example, but also traces of changing pressures, ratios, settings, quantities, automation or computer modes, rates, and so forth) and how these were presented to the people in question. Considerable domain knowledge (either from the investigator him/herself or from outside) may be necessary to determine which of the parameters could have counted as a stimulus for the behavior under investigation. The difficulty (reflected in the next step) will be to move from merely showing that certain data was physically available, to arguing which of these data was actually observable and made a difference in people's assessments and actions—and why this made sense to them back then.
4. Identify people's goals, focus of attention and knowledge active at the time
So what, out of all the data available, did people actually see and how did they interpret it? Given that human behavior is goal-directed and governed by knowledge activated in situ (Woods et al., 1994), clues are available from looking at people's goals at the time, and at the knowledge activated to help pursue them.
Finding what goals people were working on does not need to be difficult. It often connects directly to how the process was unfolding around them:
• What was canonical, or normal at this time in the operation? Tasks (and the goals they represent) relate in systematic ways to stages in a process.
• What was happening in the process managed by the people? Systems were set or inputs were made—changes which connect to the tasks people were carrying out.
• What were other people in the operating environment doing? People who work together on common goals often divide the necessary tasks among them in predictable or complementary ways. There may be standard role divisions, for example between pilot flying and pilot not-flying, that specify the work for each.
It is seldom the case, however, that just one goal governs what people do. Most complex work is characterized by multiple goals, all of which are active or must be pursued at the same time (on-time performance and safety, for example). Depending on the circumstances, some of these goals may be at odds with one another, producing goal conflicts. Any analysis of human performance has to take the potential for goal conflicts into account. Goal trade-offs can be generated by the nature of the work itself. For example, anesthesiologists need to maximize pre-operative workup time with a patient to guard patient safety and quell liability concerns, while their schedules interlock with other professions that exercise pressure with respect to e.g. timing. Goal conflicts can also precipitate from the organizational level. In this case, not all goals (or their respective priorities) are written down in guidance or procedures or job descriptions. In fact, most are probably not. This makes it difficult to trace or prove their contribution to particular assessments or actions. However, previous occurrences in similar circumstances or in the same organization may yield powerful clues. They can substantially influence people's criterion setting with respect to a goal conflict. For example, a decision to take off or not to take off in bad weather may be precluded by earlier incidents, or, conversely, encouraged by organizational reactions to lack of on-time performance.
When it comes to knowledge, not all knowledge people once showed to possess is necessarily available when called for. In fact, the problem of knowledge organization (is it structured so that it can be applied effectively in operational circumstances?) and inert knowledge (even if it is there, does it get activated in context?) should attune investigators to mismatches between how knowledge was acquired and how it is to be applied in practice. For example, if material is learned in neat chunks and static ways (books, most computer-based training) but needs to be applied in dynamic situations that call for novel and complex combinations, then inert knowledge is a risk (Woods et al., 1994).
What people know and what they try to accomplish jointly determines where they will look; where they will direct their attention—and consequently, which data will be observable to them. Recognize how this is, once again, the local rationality principle. People are not unlimited cognitive processors (there are no unlimited cognitive processors in the entire universe). People do not know and see everything all the time. So their rationality is limited, or bounded. What people do, where they focus, and how they interpret cues makes sense from their point of view; their knowledge, their objectives and their limited resources (e.g. time, processing capacity, workload). Re-establishing people's local rationality will help you understand the gap between data availability and what people actually saw or used. In dynamic situations, people direct their attention as a joint result of:
• What their current understanding of the situation is, which in turn is determined partly by their knowledge and goals. Current understanding helps people form expectations about what should happen next (either as a result of their own actions or as a result of changes in the world itself).
• What happens in the world. Particularly salient or intrusive cues will draw attention even if they fall outside people's current interpretation of what is going on.
Keeping up with a dynamic world, in which situations evolve and change, is a demanding part of much operational work, and implies two different kinds of "errors". People may fall behind during rapidly changing conditions, and update their interpretation of what is happening constantly, trying to follow every little change in the world. Or people may become locked in one interpretation, even while evidence around them suggests that the situation has changed (see De Keyser & Woods, 1990).
5. Step up to a conceptual description
The goal here is to build an account of human performance that runs parallel to the one created in step 1. This time, however, the language that describes the same sequence of events is not one of domain terms, it is one of human factors or psychological concepts. One reason for the importance of this step perhaps goes beyond the mandate of an individual investigation. Getting away from the context-specific details—in a language that may not communicate well with other context-specific sequences of events—opens a crucial way to learn from failure: discovering similarities between seemingly disparate events. When people instead stress the differences between sequences of events, learning anything of value beyond the one event becomes difficult (Rochlin, 1999). Similarities between accounts of different occurrences can point you to common conditions that helped produce the problem under investigation. Figure 2 shows the steps involved in the reconstruction of unfolding mindset.
Conclusion
The systematic investigation of human contributions to accidents is not yet a very well-established practice with common methods or assumptions. Investigators are often forced to rely almost exclusively on domain knowledge and common sense, but this exposes them to the mechanisms of hindsight. Human performance evidence can get disembodied from the flow of events that accompanied it and brought it forth; and conclusions about the human contribution easily become counterfactual and judgmental—stressing what people should have done to avoid the accident, but failed to do. None of this explains what really happened or why. There may be a need for stronger appreciation among investigators of the methodical challenges and pitfalls associated with retrospective analyses of human performance. Even clearer is the need for further development of ways in which investigators can systematically reconstruct the human contribution to accidents and avoid the biases of hindsight.
It does not describe "a series of errors that should not have been made" at all.
What it effectively says is that if we want to truly understand the cause of an accident, we have to examine the conditions and human factors that lead to or influenced the error/bad decision.
Lots of things come into play there i.e Goal focus, commercial pressure, fatigue, cognitive overload, communication problems, distraction at critical times, recallable knowledge, environment, familiarity etc etc.
What it effectively says is that if we want to truly understand the cause of an accident, we have to examine the conditions and human factors that lead to or influenced the error/bad decision.
Lots of things come into play there i.e Goal focus, commercial pressure, fatigue, cognitive overload, communication problems, distraction at critical times, recallable knowledge, environment, familiarity etc etc.
Brian those of us who are airline pilots have read through similar papers on the causes of human error and understand fully the Reason model and have the "Swiss cheese" analogy dangled in front of us every time we do a CRM refresher course. We get it, we understand it, we look for ways to avoid the holes lining up.
In addition to all the theory those of us who carry the responsibility of jet command also understand the responsibilities of been given that command. The company I work for has recently issued a FSO that restates the responsibility of the PIC. Nowhere in that document does it say that at the end of the day organisational issues and human factors will be held liable for any adverse outcome to the flight!
Your defense of Dom has never addressed the decisions he and his F/O made once they realised that they did not have the fuel to divert and the weather was below minimums. There was no attempt to buy time with the remaining FOB just blast on in, do four approaches to minima that was above the cloud base then go "oh well we've done our best lets ditch". As I have repeatedly stated and you have repeatedly ignored where was the leadership. Even when the ditching was conducted,where was the Mayday? Where was the radio call to the Unicom to say "We are ditching to the west of the island"? Where was the duty of care to his F/O when he left her unconscious in the cockpit?
So instead of plaigiarising someone elses thoughts on human factors put your own words here and explain to us why the decisions the crew made from ToD were the responsibility of CASA,Pelair and the ATSB.
In addition to all the theory those of us who carry the responsibility of jet command also understand the responsibilities of been given that command. The company I work for has recently issued a FSO that restates the responsibility of the PIC. Nowhere in that document does it say that at the end of the day organisational issues and human factors will be held liable for any adverse outcome to the flight!
Your defense of Dom has never addressed the decisions he and his F/O made once they realised that they did not have the fuel to divert and the weather was below minimums. There was no attempt to buy time with the remaining FOB just blast on in, do four approaches to minima that was above the cloud base then go "oh well we've done our best lets ditch". As I have repeatedly stated and you have repeatedly ignored where was the leadership. Even when the ditching was conducted,where was the Mayday? Where was the radio call to the Unicom to say "We are ditching to the west of the island"? Where was the duty of care to his F/O when he left her unconscious in the cockpit?
So instead of plaigiarising someone elses thoughts on human factors put your own words here and explain to us why the decisions the crew made from ToD were the responsibility of CASA,Pelair and the ATSB.
LL mate give it a break! Reading over your diatribe for the last half a dozen pages one wonders if you have a different ATSB report to everyone else. DJ has already copped the pineapple for this sordid tale what more do you want??
Maybe Dom has cut your grass with the love of your life or he pipped you at the post for some job you had dibs on, who knows??
Sounds like whatever the issue is it hasn't greatly affected your career if your flogging around with a "jet command", so FFS move on!
Maybe Dom has cut your grass with the love of your life or he pipped you at the post for some job you had dibs on, who knows??
Sounds like whatever the issue is it hasn't greatly affected your career if your flogging around with a "jet command", so FFS move on!
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It does not describe "a series of errors that should not have been made" at all.
What I said
try and describe what was in effect a series of errors that should not have been made.
That verbiage could be broken down to the first commandment.
Thou shalt not make a stuff up or the ground (in this case water) will arise and smite thee.
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Your defense of Dom has never addressed the decisions he and his F/O made
The company I work for has recently issued a FSO that restates the responsibility of the PIC
0.1 COMPLIANCE REQUIREMENTS
0.1.1 This Manual lays down the Company's standard instructions and procedures for flying operations and defines the duties and responsibilities of all aircrew. These instructions and procedures are mandatory for all aircrew, and shall be a condition of employment with the company.
0.1.2 Failure to observe these instructions or procedures may invoke severe penalties upon the Company. The Company therefore reserves the right to take disciplinary action against any person who fails to comply with these instructions or procedures.
0.1.3 This Manual shall not supersede or countermand any Regulations, Orders or Instructions issued by the Civil Aviation Safety Authority. Compliance only with the terms of this Manual shall not absolve any personnel from the responsibility of abiding by such Regulations, Orders and Instructions.
0.1.4 It is not the intention of this Manual to list all possible illegal activities. All pilots must therefore realise that any operation outside the guidelines of the CAO's, CAR's and this Manual may have severe legal implications on the Company. Illegal activities by pilots may result in action under the Company Disciplinary policy in force at the time.
0.1.1 This Manual lays down the Company's standard instructions and procedures for flying operations and defines the duties and responsibilities of all aircrew. These instructions and procedures are mandatory for all aircrew, and shall be a condition of employment with the company.
0.1.2 Failure to observe these instructions or procedures may invoke severe penalties upon the Company. The Company therefore reserves the right to take disciplinary action against any person who fails to comply with these instructions or procedures.
0.1.3 This Manual shall not supersede or countermand any Regulations, Orders or Instructions issued by the Civil Aviation Safety Authority. Compliance only with the terms of this Manual shall not absolve any personnel from the responsibility of abiding by such Regulations, Orders and Instructions.
0.1.4 It is not the intention of this Manual to list all possible illegal activities. All pilots must therefore realise that any operation outside the guidelines of the CAO's, CAR's and this Manual may have severe legal implications on the Company. Illegal activities by pilots may result in action under the Company Disciplinary policy in force at the time.
What does "S" stand for in CASA? The above situation has a Norfolk Island set up all over it, just waiting for an unfortunate event to catch a crew out.
When you get a spare moment from swanning about in your shiny jet you might get the dictionary out and look up plagiarise for its correct definition.
That is an awful lot of verbiage to try and describe what was in effect a series of errors that should not have been made.
Last edited by Brian Abraham; 30th Sep 2012 at 02:22.
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What it effectively says is that if we want to truly understand the cause of an accident, we have to examine the conditions and human factors that lead to or influenced the error/bad decision.
“Maybe Dom has cut your grass with the love of your life or he pipped you at the post for some job you had dibs on, who knows??” Yep, a fairly standard reply from you Sarcs…
While I personally believe the company (and to a lesser extent CASA) had a significant role in this event, I do think Lookleft makes a number of very valid points.
Cheers.
VH-MLE
While I personally believe the company (and to a lesser extent CASA) had a significant role in this event, I do think Lookleft makes a number of very valid points.
Cheers.
VH-MLE
Sarcs I wasn't the one who resurrected this thread when it was about to drop off the bottom of the page then post a large document so if you don't want your obvious biases to show you would direct some of your vitriol to BA as well. I do get annoyed however when people suggest (of which you are one) that the PIC has been set up by the nasty authorities and that he was an innocent victim in what occurred. And despite your purile assertions about my connections with Dom the only contact I have had with him is through the television screen and what I saw was someone who was trying to deflect responsibility for what occurred. I am happy to let this go and I look forward to the Senate Enquiry but I will keep on posting to put forward the view, as others such as blackhand and dora-9 have, that the PIC is the PIC is the PIC!
Last edited by Lookleft; 30th Sep 2012 at 02:43.
I was reminded many months ago, by others who are very experienced pilots with many years of flying behind them, that just because something is legal, doesn't make it a great or sensible idea. It's then at the PIC's discression as to whether to take advantage of this legality, or whether it's not a good idea for their flight.
I've stated several times on this thread, the PIC is the PIC.
morno
I've stated several times on this thread, the PIC is the PIC.
morno
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Stand back, sprinkler in use!
PIC - A ‘Peripherally Inserted Central Catheter, an intravenous access that can be used for a prolonged period of time.
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direct some of your vitriol to BA
Quite a few in the industry are predicting a smoking hole made by a shiny jet in Oz. Should you be in the drivers seat Lookleft I presume it will be OK by you if I post on Pprune that it was all your fault.
Anyone that didn't know the definition of plagiarise at an interview board would surely get the thumbs down.
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That they should not have been made is obvious, even to a blind man.
The question that has not been answered is why they were made
Last edited by prospector; 30th Sep 2012 at 22:02.
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Do you think those questions will ever be answered to everybodies satisfaction?? I would think not.
I've never had anything to do with horses, but I'm told you can lead them to water but you can't make them drink
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Quite a few in the industry are predicting a smoking hole made by a shiny jet in Oz. Should you be in the drivers seat Lookleft I presume it will be OK by you if I post on Pprune that it was all your fault.
You are so right. There are still people who believe the earth is flat
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Well with a smoking hole one can assume he didn't run out fuel
Whilst you appear to believe that it may be cuboid