Human error is a prevalent finding in many accidents involving complex socio-technical systems. Within the aviation domain it is common to see statements that 70% to 80% of aircraft accidents are caused by pilot error or that 85% of work accidents are due to unsafe acts by humans rather than unsafe conditions (Leveson, 1995).
The systems view supports a complexity perspective, where the attribution of pilot error is seen as an oversimplification of a complex aetiology resulting from a number of causes (Shappell & Wiegmann, 2001). This paper, stemming from a research initiative entitled “Fratricide in Air Operations: Opening the Black Box, Revealing the Social”, presents an argument that human error, crew or pilot error represents a limited view of accident causation and reflects a fundamental misunderstanding regarding the aetiology of aviation accidents. The black box we call pilot error has become an opaque representation of a complex problem space. It is by opening the black box that we reveal the ‘social’ that characterizes the accident aetiology associated with fratricide. Senge (1990) reveals that since the world exhibits qualities of wholeness, the relevance of systemic thinking is captured within its paradigm of interdependency, complexity and wholeness. Through the systems perspective of Actor Network Theory, informed by complexity theory and facilitated by Grounded Theory, the analysis reveals that ‘operationalizing’ a Knowledge Management and Organizational Learning solution requires acknowledging the relationality inherent within a network of heterogeneous elements without privileging either the human or non human. It is about recognizing the barriers to successful Knowledge Management and Organizational Learning that reside within the traditional Cartesian-Newtonian paradigm of linearity and reductionism. This paper presents the results of an analysis of fratricide incidents, from the ANT worldview and identifies Knowledge Management and Organizational Learning insights as part of the solution space.
|Keywords:||Knowledge Management, Organizational Learning, Systems Thinking, Fratricide|
Graduate Student, Department of Criminology, University of Leicester, Leicester, UK
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