Putting the “Who” Into It
Posted October 16, 2012
In California, a 31-year-old O-3 was driving his home from an extended session at a local bar. It was 3:55 a.m. He came to a sharp left turn, followed by a sharp right turn.
Here’s how the mishap report described what happened next: the Ford Explorer he was driving “failed to follow the roadway, crossed over to opposite left lane and struck the guardrail.”
No. The Ford didn’t fail to do anything. It was operating just fine. It started when he had stabbed his key into the ignition, and it had moved forward when he put it in gear and stepped on the gas.
All of the failures leading up to the wreck were human. The driver failed to stop drinking when he’d had a reasonable amount. He failed to call a cab when his BAC was 0.151. He failed to realize that trying to drive home was the worst idea he’d had in a long time. When he got to the curve, he failed to slow down. And then he failed to keep control of his vehicle, which, by the way, skidded along the guardrail, flipped over the guardrail, and then rolled down into some woods.
The only good thing was that he hadn’t been too drunk to forget his seatbelt. He ended up with severe trauma to his head and a concussion.
Here’s another example, a civilian woodworker who had just finished using a nail gun. “He laid the gun down with the nailing end pointing towards him,” the mishap report said. “It went off, shooting a nail through the index finger of his left hand.”
“It went off”? Is that what those things do? Doesn’t that make them a little hard to use, not to mention dangerous, being so inherently unpredictable? On the last nail gun I used, you had to make it go off by pressing a trigger.
Back in the day, especially around aviation maintainers, you always heard about “Murphy’s Law,” which, in its original and purest form, was this: “If it is possible to install a part two different ways, and one way in right and the other is wrong, sooner or later someone will install it wrong.” This law said a lot about human error and the need for QA.
But through the years, the law got bastardized into something more on the order of “Bad stuff happens.” It wasn’t human error. It was bad luck, or being in the wrong place at the wrong time, or some other manifestation of malign destiny.
It reminds me of the report about a culinary specialist third class in Florida who was opening a can when he simultaneously, painfully and bloodily opened his thumb. "Member was a victim of circumstance," the report said.
Sorry, I don’t buy it. You can’t be a victim of circumstances that you create, any more than that drunk O-3 was a victim of the circumstance of a sharp turn on a dark road.
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