Punishing human error will not eliminate accidents that lead to tragedies. For that, authorities must tackle the root causes of carelessness.
School bus accidents and the inevitability of human error
In April 2008, human error claimed the life of a three-year-old boy. Aastish Shabin died of unknown causes after being left alone on a school bus overnight. Twelve months later, the UAE lost another child, this time four-year-old Aiman Zeeshanuddin, who died of dehydration after she also was left on a bus. And less than two weeks ago, a three-year-old girl whose identity was not released was killed when a school bus backed over her.
In the face of such events, the tragedy is hard to fully comprehend.
As a student of the psyche, I am very familiar with human fallibility. To err is undeniably human, and often predictably so. Every person reading this article has, for example, sent an email forgetting to add the attachment. Such errors we call slips or lapses: unintentional errors of memory and attention.
Farther up the hierarchy of human error are reasoned and routine violations. These are intentional errors or transgressions, such as speeding ("because the road is open"), failing to wear safety belts ("because I'm only going around the corner"), or leaving litter such as glass bottles on the beach. I have heard this last one rationalised as: "It provides employment." Employment for who? I guess for crews that clean the beaches, and the medics who stitch the lacerated feet of children.
It's easy to see how one person's reasoned violation is another's reckless act. Less open to interpretation, however, is a category of error bordering on cruelty and criminality: malicious violation. These acts are rare as few people actively deviate from prescribed behaviour with the intention of causing harm or distress.
But the more blameless errors are extraordinarily common. As in the case of the school bus accidents, human error is often implicated in the worst incidents, regardless of what a person's intentions were. The problem is that people reflexively look for someone to blame.
Punishing a person for a lapse cannot be justified; it certainly does not prevent similar events and in many cases it creates a culture of fear that is hardly conducive to safety.
If we are to prevent similar tragedies, we need to look beyond human error for the answer. Root cause analysis, a systematic method of incident investigation, might prove useful. RCA, as it is known, is essentially a method of looking beyond human error and focusing on the systems and environmental factors that contribute to events. Widely used in health care and aviation, the same principles are applicable to the school safety issue.
One of the key techniques is known as barrier analysis, which looks at minimising the recurrence of root causes. Barrier analysis suggests three categories: human, administrative and physical. Administrative barriers include policies and regulations on, say, how we record and report absences from school. Human barriers depend on assigning people particular roles, perhaps as bus monitors.
In both of these cases, we arrive back at the problem of human error, all too susceptible to slips, lapses, reasoned and even reckless violations. These solutions should not be ignored, but in a way they bring us back to the original problem.
Physical barriers, then, can often be relied upon to provide the optimal solution, if not a total fail-safe. Typically physical solutions are engineered with the goal of making an error more difficult, if not impossible.
Consider for example the lift door fitted with a sensor that will not allow the door to be closed if it detects an object in the entrance. Or the mall door that opens automatically, but only if a sensor detects an object over a certain height, which stops small children from wandering outside.
It is not difficult to envisage a "safe" school bus fitted with physical barriers that could make accidents more unlikely.
The best solution in a complex situation will often be a balance of all three types of barriers. We have seen the headline "Child dies in school bus tragedy" too many times. Authorities need to take another look at the root causes.
Justin Thomas is a psychology professor at Zayed University