The Organisational Perspective
The Organisational Perspective understands the complex nature of performance and error causation; that it does not just involve pilots and their aircraft (Wiegmann & Shappell, 2003). The perspective places an emphasises on the fallibility of the decision making of an organisation’s managers and supervisors.
Birds Domino Model is the best known organisational model of human error (1974, cited in Wiegmann & Shappell, 2003). The model follows the argument that an accident is the result of a series of events. The ‘Domino Effect’ starts with managers who fail to either plan to control safety or fail to implement any plans they have, which can result in basic personal and job related problems. These basic causes lead to intermediate causes, such as unsafe acts or conditions, which can ultimately lead to accidents causing injury or loss. Adams (1976, cited in Wiegmann & Shappell, 2003) renamed the first three dominos; management structure, operational errors and tactical errors, respectively.
|The Domino Model of Accident Causation (image embedded from [http://www.ilo.org/safework_bookshelf/english?content&nd=857170696] on 31 August 2010)|
A different organisational model aimed directly at understanding flight deck operations was devised by Degani and Wiener (1994, cited in Wiegmann & Shappell, 2003). The Four ‘Ps’ of Flight Deck Operations Model focuses on the relationship between management Philosophy, operational Politics, operational Procedures and aircrew Practices. Factors which interact to enhance safety and if any factor is ambiguous an error can occur.
A major advantage of the Organisational Perspective is that it views performance, and hence error, as something that can be managed. A disadvantage of the perspective is that operators, such as pilots, are often far removed from the time and place where the organisational error occured, making the linking of pilot error with a particular organisational event difficult in accident investigations. Also a full understanding of how organisational events manifest themselves as errors has yet to be developed; Are there single or multiple causes? Was the error the organisation’s or the pilot’s fault?. The Organisational Perspective tends to foster the idea that every error is in some way a function of the organisation.
Want to know more?
- Other Perspectives
- An introduction to other perspectives for understanding human performance and error.