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Consequences

Feedback from airline LOFT programmes show that violations occur regularly. Furthermore, one third of violations are mismanaged, and lead to further violations or errors. Such data comes from day-to-day routine operations where no negative consequences occurred. This is in contrast to accidents and incidents whose negative outcomes are too often linked with human error and procedural noncompliance (some examples of which are described below in this Article).

Some violations, therefore, do cause or contribute to negative consequences, but many do not. Although, from experience we know that the more unsafe acts that occur without negative consequences, there is an increased probability of negative consequences from some of them (Heinrich Pyramid). Because aviation workers mostly do not experience any direct cause-to-negative effect when they commit a violation, then the degree of risk can remain unconsidered. Furthermore, when violations result in positive outcomes, the possibility of any additional risk is not considered. There may seem to be no visible drawbacks to violating; instead, just positive reinforcement of the violating act.

Unless openly discussed during training (e.g. CRM and TRM) or debriefing normal operations, lessons may not be learnt from violations as they remain “taboo”. Ironically, violators may assume that other humans in the system are operating and performing normally (i.e. no other errors or violations): whereas, the possibility should always be considered as a potential threat.

Therefore, it is important to realise that when negative consequences do occur as a result of a violation (apart from sabotage), the person committing the violation did not intend the dramatic negative consequences. Instead they believed that the situation remained under control despite the violation. This is why violations mostly do not demand punishment.

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