When an error is not an error…

If we are going to learn from the tragedy of the Costa Concordia, the cruise ship that ran aground off the Italian coast, we have to be brutally honest.

While investigations continue we should keep an open mind about the possible causes and not automatically assume, like some media coverage, that the captain is totally at fault. However, it is inevitable that human factors contributed to this incident, as they do to every workplace accident and injury. Human factors encompass both errors and violations – two separate things which need to be treated separately. Camouflaging a violation as an error may be more palatable in the short term, but in the long term it does no one any favours.

The CEO of Costa Cruises was quoted as saying: “we cannot deny human error”. But he alleged that the captain of the Costa Concordia had sailed his ship away from its intended route to show it to people on a nearby island, ignoring the alarms that would have been sounded by the ship’s navigational computer.

It concerns me that the captain’s actions have been labelled as human error. If the allegations are true, what happened was actually a violation; a conscious, deliberate decision to deviate from the established safety procedures.

Violations are largely caused by our perception of the way things normally get done – the culture. To eliminate violations, what’s needed is a positive safety culture. If violations are never questioned, they become the norm, and people start to think there is no risk. Companies should develop a culture where everyone is encouraged to praise safe behavior and challenge unsafe behavior. That way violations become rare.

Errors, on the other hand, are honest mistakes, things we didn’t mean to do in the first place. They are caused by things like tiredness, distraction and frustration. It would be easy to trivialize them and regard them as inevitable. But that needn’t be the case; we just need to correctly identify what is error and what is violation.

We can’t suddenly decide to never be tired again to eliminate error. But often the number of injuries sustained due to error can be reduced if people are trained to spot the signs.

So, the direct cause of the Costa Concordia accident was not, apparently, a mistake. To reduce the likelihood of future incidents, we must acknowledge not just that an error is different from a violation, but so are the causes and methods we should use to eliminate them.

I hope the Costa Concordia investigation recognises what were errors and what were violations, and strives to identify the real causes of each. If the investigation into this, and any other, incident regards violations and error as the same thing, it is difficult to see how effective preventative measures will be selected.

Additionally, I hope it establishes whether deviations from approved routes at the whim of the captain were commonplace in the Costa culture or whether this was a genuine one-off. This will help to identify who is truly culpable. A no-blame policy is often referred to when developing workplace safety culture. But, occasionally, making people accountable for their actions is the right thing to do. What we should really be developing is a safety culture that is just – and we will explore that concept further next time.

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