The Nimrod Review - Official Documents

Chapter 18 – Accident Theory and High-Risk Technologies
18.9 Seventhly, do not simply blame individuals whilst ignoring more fundamental organisational causes. Human
error does not take place in a vacuum. Investigators of accidents often fall prey to the temptation to focus
simply on performance of individuals whilst ignoring the organisational deficiencies which may have caused
or contributed to the individuals’ ignorance or sub-optimal performance. Such flawed attribution sometimes
arises because of the relative ease with which it is possible to point to individual human failures and the
relative difficulty in identifying and analysing the more complex ‘task’, ‘situational’, ‘institutional’ and/or
‘organisational’ factors that shape human performance. Most people involved in serious accidents are neither
stupid nor reckless, although they may have been blind to the consequences of their actions. 11 Key to any
accident investigation is understanding why they acted as they did and the organisational factors that shaped
their approach and behaviour.
The importance of investigating organisational causes
18.10
The importance of looking at organisational causes was recognised by International Civil Aviation Organisation
(ICAO) in the 1990s when the following passage was added to its Annex 13 regarding the standards and
recommended practices for air accident investigators throughout the world:
“1.17. Organisational and Management information [that accident reports should include].
Pertinent information concerning the organisations and their management involved in
influencing the operation of the aircraft. The organisations include, for example, the
operator, the air traffic services, airway, aerodrome and weather service agencies, and the
regulatory authority. The information should include, but not be limited to, organisational
structures and functions, resources, economic status, management policies and practices,
and regulatory framework.” 12
18.11 In their book Beyond Aviation Human Factors, 13 Maurino, Reason, Johnston and Lee examined how the
scope of accident analysis had been extended from the individual to the collective, i.e. managerial and
organisational. The authors emphasised that human error does not take place in vacuum, but within the
context of organisations which either resist or foster it. The central contention of their book (with which I
concur) is succinctly put as follows:
“[N]o matter how well equipment is designed, no matter how sensible regulations are, no
matter how much humans excel in their individual or small team’s performance, they can
never be better than the system that bounds them.” 14
The Dryden Report (1992)
18.12
The central case study considered by the authors of Beyond Aviation Human Factors is the inquiry by the
Honourable Mr Justice Virgil P Moshansky into the crash at Dryden, Ontario, on 10 March 1989. 15 The cause
of the accident was pilot error: Captain Morwood failed to de-ice the wings of his Air Ontario F-28 jet causing
Flight 1363 to crash shortly after take off. The authors said the investigation might have been closed within a
few weeks of the crash, had conventional wisdom been applied. In ‘The Dryden Report’, however, Moshansky
“tore apart” the Canadian aviation system, and adopted a system-analysis approach, with emphasis on an
examination of human performance. Commenting on his report Commissioner Moshansky later said:
“Whenever human beings are involved in a complex system, there will be failures both
active and latent. The concept of human factors contributing to aviation accidents has
been around since the 1930’s, when it was first advanced by Dr Robert McFarland, a
renowned American Psychologist. However, cynicism and a lack of understanding of
the concept prevailed, with the result that accident investigations generally ignored it or
regarded it with scepticism, until Dryden.
11 See James Reason, Human Error, 1990, page 216.
12 See Ninth Edition of ICAO Annex 13 (Aircraft Accident and Incident Investigation), July 2001.
13 Daniel E Maurino, James Reason, Neil Johnston and Rob B Lee, Beyond Aviation Human Factors, 1995.
14 Ibid, pages x-xi.
15 Final Report of the Commission of Inquiry into the Air Ontario Crash at Dryden, Ontario by Honourable Mr Justice Virgil P Moshansky (1992).
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