How not to prevent accidents

A French court yesterday found Continental Airlines guilty of involuntary homicide for its part in the Concorde crash outside Paris in 2000. This is regrettable, since criminalising accidents is not an intelligent approach to managing risk.

The reason Continental found itself in the dock on this case was that the last plane to take off before Concorde, a Continental DC10, shed a small piece of titanium that then punctured a tyre on the Concorde, which then led to shards of rubber flying into the fuel tanks. Not only was Continental prosecuted, but so was the individual mechanic – one John Taylor, who’s been given a fine and a suspended sentence.

Compare this to the approach taken to error reporting in high-reliability organisations. Here are Karl Weick and Kathleen Sutcliffe in their classic book on the subject, Managing the Unexpected:

The best high reliability organisations increase their knowledge base by encouraging and rewarding error reporting, even going so far as to reward those who have committed them … researchers Martin Laundau and Donald Chisholm provide [the example of] a seaman on the nuclear carrier Carl Vinson who reported the loss of a tool on the deck. All aircraft aloft were redirected to land bases until the tool was found, and the seaman was commended for his action – recognizing a potential danger – the next day at a formal ceremony.

That’s what you want to happen – a transparent organisational culture that displays what Weick and Sutcliffe call ”a preoccupation with failure”.

It’s also the precise opposite of what the French court has effectively just ensured – which is that mechanics will keep schtum about their mistakes in case they get prosecuted. Not clever.