l cycle of blame~

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Malcolm Scott

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Introduction
Commercial aviation stands at a crossroads. Aircraft operation has developed to a point
at which the control and decision-making functions are shared between pilots and com-
puters. Meanwhile this most important pilot skill, decision making, appears to be inade-
quately trained and supported by the airlines.' The future course of the profession and
the industry depends on the way in which airlines choose to manage the changing pres-
sures and demands placed on their pilots.
This two-part article is based on the work of Professor James Reason of Manchester
University. His book, 'Managing the Risks of Organizational Accidents", proposes a
change in the way we think about and manage the human side of aircraft operation.
This article will describe how a powerful bias in human thinking leads to a 'cycle of
blame', which diverts attention away from the underlying causes of human errors. It
will compare three models of management and will attempt to explore the characteris-
tics of a 'safety culture'.

T he manager's article. To set the The Person Model of Management

scene, consider the following
extracts from an article written by
a senior airline manager and published
April 2004. The piece begins by describ-
ing three instances in which a company
standard operating procedure (SOP) was
not followed and goes on to advise that,
, ...failure to correctly follow this SOP
will be viewed as a serious breach of com-
pany safety policy and dealt with as such'.
The article then lists ten events that
might be described as human factors
errors. The author writes that, 'it is not
easy to try to identify any particular cause
for these events but they have neverthe-
less taken up quite a lot of time as we try
to understand what took place and more
The striking thing about this article is that
all ten causal factors cited by the manag-
in er were pilot-centred. Perhaps this is
understandable since between 66% and
80% of accidents have been ascribed to
human error. When looking for possible
causes of incidents it would therefore
seem sensible to look to possible 'human
factors'. When seeking to manage the
risks of flight operations it would seem
logical to concentrate on 'people man-
agement'. Professor Reason identifies this
approach as the 'person model of man-
agement"
The person model of management
views people as capable of choosing
between safe and unsafe behaviour, thus

importantly why'. errors are caused by psychological factors

The article then asks if there is any such as poor motivation, or carelessness.
connection to these events: 'might the The task of managers is seen as encour-
causes include: aging, constraining or 'driving' people to
.Lack of airmanship? choose correct, safe behaviours. Typical
.Lack of professionalism? management tools include retraining,
.Lack of self-discipline? writing another procedure, exhortations Acts of recklessness cannot
.Lack of attention ? to the staff to be more careful and
be condoned. But in the vast
.Lack of CRM? threats of sanctions if they don't comply.
.Lack of monitoring? Error management (EM) programmes majority of cases, where well-
.Lowarousallevels? tend to be targeted at the individual.
...low experience... over-confidence or However, Reason' points out that many intentioned individuals make
complacency?' such programmes are, '... reactive rather
errors, the assignment of
than proactive, event-driven rather than
The author declared that he would be principle-driven. They also largely ignore blame is ineffective and likely
delighted to discuss these issues but the substantial developments that have
retired within a month! occurred in the behavioural sciences over to make matters worse

14 THE LOG June:July 2005 BL\LPL\

 flight safety. See fig 1 .
the last 20-30 years. ..Some of the problems course, lies somewhere in between'.
Of course an entirely blame free culture is
associated with existing forms of EM include the The reason for this tendency or bias in
untenable. Acts of recklessness cannot be
following: human thinking is not fully understood but
condoned. But in the vast majority of cases,
.They "firefight the last error rather than antici- its existence is well established. It has many where well-intentioned individuals make
pating and preventing the next one" . adverse effects in society. For example it errors, the assignment of blame is ineffective
.They focus on active failures rather than latent puts the 'us and them' into industrial rela- and likely to make matters worse.
conditions. tions, international relations, political rela- What is needed is a more sophisticated
.They focus on the personal, rather than the tions and personal relations as each side way of looking at aircraft accident causa-

situational contributions to error. underestimates the contextual constraints tion. Part two of this article will look

on the other. In the aviation safety field, beyond the blame cycle and the person
.They rely heavily on exhortations and discipli-
model of management. It will introduce
nary sanctions. Adam Hunt' has concluded that, 'decades
the engineering and organizational models
.They employ blame-laden and essentially of research have shown that a focus on
of management and will attempt to
meaningless terms such as "carelessness". personality factors is ineffective in prevent-
explore some of the characteristics of a
"bad attitude", "irresponsibility" -even in ing accidents, and that situations over-
'safety culture'.
Total Quality Management (TQM). whelm personality variables.' Yet the fun-
.They do not distinguish adequately between damental attribution error persists and
random and systematic error-causing factors. leads directly to the 'blame cycle'. References
1. See myarticles, 'Decision Making on the
.They are generally not informed by current
Flight Deck: Where do We go from Here?'
human factors knowledge regarding error and The Blame Cycle
(submitted to 'Flight-Deck? and 'From Airline
'Blame', 'fault' and 'guilt' are highly emo- Pilot to Airline Machine-minder' in the 'Log',
accident causation.'
tive words. Fundamentally, people like to October 2004 for more on this.
feel good about themselves so it hurts to 2. Reason, J., (1997) 'Managing the Risks of
An example of the person management style
be on the receiving end of one of these Organizational Accidents', (Aldershot: Ashgate).
was British Rail's approach to 'signals passed at
words. Yet we live in a blame culture: par- 3. Hunt, A. (2004) The Importance of
danger' (SPAD's). Much management time and Situational Factors in Aviation Safety or
ents blame their children, teachers blame
money was directed at trying to identify those the parents, the government blames the Situations and How to Control 77Jem" 'Flight
train-drivers likely to cause SPAD's. This search Deck' issue 38
teachers and everyone blames the govern-
ignored the fact that the vast majority of SPAD's ment! Likewise, the fundamental attribu-
About the author
occurred at a tiny number of signals! In their tion error and the person model of man-
Malcolm Scott has been flying commercial
search for the cause of errors these managers agement tend to lead to the managers aircraft for 26 years. He has flown several
were so focused on people management that blaming the pilots and the pilots blaming aircraft types from the DC3 Dakota to the
they took their eyes off the primary cause of the the managers. The culture is so ingrained Airbus A320 series for six different airlines.
that when pilots make mistakes we auto- He gained a good honours degree in psy-
problem -the workplace environment.
matically tend to blame ourselves. chology as a mature student and has carried
So why, many years later, do managements per-
Unfortunately this culture does nothing for out research into airline decision making.
severe with the person model7 It is of course very
difficult for individuals to change long held atti-
tudes and beliefs. Such attitudes are self-perpetu-
ating as each management team recruits future
managers with similar attitudes to their own. Also,
in our increasingly litigious climate, Reason points
out that: 'It is much easier to pin the legal respon-
/
" ,
sibility for an accident on the unsafe acts of those Why? People are
Errors are now
at the 'sharp end' Moreover the person model is seen as free agents
regarded as being
very appealing in a culture that believes in free will able to choose
even more blame-
and personal agency. between correct
worthy, since they
and erroneous
seem to ignore
The Fundamental Attribution Error actions
warnings etc.
One reason for this appeal is known as the 'fun-
damental attribution error'. This term refers to a
powerful tendency for people to attribute
events to the personal characteristics of the indi- "'
vidual(s) involved and to underestimate the
importance of the context in which the event
took place. Reason explains: 'When we see or
hear of someone performing badly, we attribute
this to some enduring aspect of the individual's
personality. We say that he or she is careless,
silly, stupid, incompetent, reckless or thought-
less. But if you were to ask the persons in ques-
tion why they are behaving in this fashion, they
would almost certainly point to the local situa-
tion and say they had no choice -circumstances
forced them to do it that way. The reality, of
"
Fig The blame cycle (after Reason)
BL\LPL\ June:July 2005 THE LOG 15