Free sample lesson
Free sample lesson, the three categories of behaviour
A reading version of lesson 2.2. In the course the questions are interactive; here they are shown with their answers.
2.2 The three-part model, error, at-risk and reckless behaviour
After this lesson you can:
- Classify an event as human error, at-risk behaviour or reckless behaviour, and justify it
When something has gone wrong, somebody has to decide what happens next. This lesson gives you a tool for that: three categories of behaviour, each with its own response. The model was developed by David Marx and builds on James Reason’s work on safety culture.
Recall
Which of these are judgement traps from lesson 2.1?
- Hindsight bias
- Outcome bias
- Local rationality
Answer: Hindsight bias; Outcome bias
- Hindsight bias: Yes.
- Outcome bias: Yes.
- Local rationality: No. Local rationality is the tool against the traps, not a trap.
The third trap is attribution error.
According to lesson 2.1, what is the first question after an event?
- What did the person know at the time, and why did the action make sense?
- Who is to blame?
Answer: What did the person know at the time, and why did the action make sense?
- What did the person know at the time, and why did the action make sense?: Correct.
- Who is to blame?: No. That is the old view.
Three kinds of behaviour
Human error
An unintended action: a slip, a lapse or a mistake. The person meant to do the right thing.
Example: The pilot presses the wrong button when changing flight mode, because two buttons sit close together and look alike. The drone changes mode for a moment, and the pilot corrects it at once.
Response: Support the person. Look at the system: is the display, the procedure or the training good enough?
At-risk behaviour
A deliberate choice that increases risk, where the person did not see the risk as significant, or believed it was justified. Often it has become normal in the group.
Example: The pilots regularly fly a little lower than planned to save battery and time. Everybody does it, and it has always been fine.
Response: Coach, do not punish. Help the person see the risk. Remove what makes the shortcut pay, and check whether the procedure is too impractical.
Reckless behaviour
A conscious choice to disregard a risk the person knew was significant and unjustifiable.
Example: The pilot flies in thick fog far below their own minimums, knowing the operations manual forbids it, because the client is pushing. There is no emergency.
Response: A fair and documented process, which may lead to consequences. Just culture does not protect against consequences here, but it makes sure the process is fair.
What separates at-risk behaviour from reckless behaviour?
- Whether the person knew the risk was significant and unjustifiable
- Whether it went wrong or not
- Whether the person is experienced or not
Answer: Whether the person knew the risk was significant and unjustifiable
- Whether the person knew the risk was significant and unjustifiable: Correct. In at-risk behaviour the person did not see the risk as significant. In reckless behaviour they knew, and chose anyway.
- Whether it went wrong or not: No. The outcome does not decide the category. It is the behaviour that is assessed.
- Whether the person is experienced or not: Experience affects what the person should have understood, but it is not what separates the categories.
One deviation, three explanations
Pilot Erik is inspecting a bridge beyond visual line of sight. The flight log shows he flew 40 metres above the height the operations manual allows. The Safety Manager asks him for a conversation. The category depends entirely on the explanation.
| Erik explains | Assessment | Response |
|---|---|---|
| He received new airspace information just before take-off, updated the plan, but by a slip loaded yesterday’s parameter file. No alarm warned him | Human error | Support Erik. Find out why no alarm warned him. Add a check of the parameter file to the checklist |
| He flew a little higher to get better images, thought it was close enough, and knows several colleagues do the same | At-risk behaviour | Coach. Go through why the limit is there. Check whether the procedure is clear enough |
| He knew about the limit and about a military exercise in the area, but flew higher anyway to finish on time and earn a bonus for delivery | Reckless behaviour | A fair and documented process. Look at the bonus scheme as well |
Notice the last row. Even when behaviour is reckless, it is worth asking what in the system made the choice tempting. Here it was a bonus for fast delivery.
Why is it impossible to categorise Erik’s deviation from the flight log alone?
- Because the category depends on what Erik knew and chose, and the log does not show that
- Because 40 metres is always human error
Answer: Because the category depends on what Erik knew and chose, and the log does not show that
- Because the category depends on what Erik knew and chose, and the log does not show that: Correct. That is why the assessment must rest on a conversation, not only on data.
- Because 40 metres is always human error: No. The same deviation can fall into any of the three categories.
The decision tree
The tree asks three questions in order:
- Did the person act as they intended? If not, it was a slip or a lapse: human error.
- Did the person see that the choice carried a real risk? If not: at-risk behaviour.
- Was there a good reason to take the risk, for example an emergency? If yes, it was a justified choice. If not: reckless behaviour.
At every step, use a check: would a colleague with the same experience and training have done the same in the same situation? If the answer is yes, the explanation probably lies in the system, not in the person.
One important caveat: the categories are the organisation’s tool for choosing a fair response. They are not the same as the legal concepts of “gross negligence” and “wilful” conduct. What counts as gross negligence in law is decided by authorities and courts under their own rules.
A pilot forgot to switch on logging before a flight, noticed after landing and reported it. Where do you stop in the tree?
- At the first question, because it was a lapse
- At the third question, because logging is required
Answer: At the first question, because it was a lapse
- At the first question, because it was a lapse: Correct. It was not a choice. Human error, and check whether the logging step can be made easier.
- At the third question, because logging is required: No. You do not get that far. Forgetting was not a choice.
Practise on five cases
Use the decision tree on each case. The answer and the reason appear straight away.
Case 1: A pilot no longer checks current airspace information before flying, because “there is usually nothing there”. Colleagues do the same. Nothing has happened yet.
- Human error
- At-risk behaviour
- Reckless behaviour
Answer: At-risk behaviour
- Human error: No. It is a deliberate choice, not a slip.
- At-risk behaviour: Correct. A normalised choice where the risk does not feel significant. Coach, and make the check part of the checklist.
- Reckless behaviour: Not here. The pilot did not see the risk as significant, and everyone in the group does the same.
Case 2: A pilot flies in rain beyond their own minimum because the client called and pushed. The pilot knew perfectly well why the limit is there. No damage.
- Human error
- At-risk behaviour
- Reckless behaviour
Answer: Reckless behaviour
- Human error: No. It was a deliberate choice.
- At-risk behaviour: Not here. The pilot knew the risk was significant.
- Reckless behaviour: Correct. A known, significant and unjustifiable risk. A fair process, and look at how client pressure is handled too.
Case 3: A pilot misreads the briefing and flies in the wrong corridor, 200 metres from the right position. The map in the operations manual is unclear, and three other pilots have made the same mistake.
- Human error
- At-risk behaviour
- Reckless behaviour
Answer: Human error
- Human error: Correct. And when several people make the same mistake, it is a clear sign the map needs improving.
- At-risk behaviour: No. The pilot did not choose to fly the wrong way.
- Reckless behaviour: No. There was no conscious risk.
Case 4: During a flight the airspace observer leaves the post for private reasons. The pilot carries on anyway, knowing it breaks the procedure and makes the flight unsafe, and with no reason that makes it necessary.
- Human error
- At-risk behaviour
- Reckless behaviour
Answer: Reckless behaviour
- Human error: No. It was a deliberate choice.
- At-risk behaviour: Not here. The pilot knew the procedure was broken and why it exists.
- Reckless behaviour: Correct. But look at the observer too, and at how it was possible to leave the post without the flight being stopped.
Case 5: A pilot lands at an unapproved site because the drone loses power over a housing estate. The nearest approved site was too far away. What is the right assessment?
- A justified choice, because there was a good reason to take the risk
- Reckless behaviour, because the landing site was not approved
Answer: A justified choice, because there was a good reason to take the risk
- A justified choice, because there was a good reason to take the risk: Correct. An emergency can make a deviation the best choice. Learn from the situation, and check whether the procedure says enough about emergency landings.
- Reckless behaviour, because the landing site was not approved: No. There was a good reason to depart from the plan.
Take this with you
The decision tree is the first version of R3, the method for fair assessment. You adapt it to your organisation in module 5. You can already use the checklist below in your next case.
Fair assessment, version 1 (R3)
- The facts are established before anyone assesses behaviour
- The person has been able to say what they knew and thought
- The three questions in the decision tree are answered in order
- The check is done: would a colleague have done the same?
- The assessment rests on the behaviour, not the outcome
- What in the system made the action possible or tempting is recorded
- The assessment and its reasons are written down
Two pilots make the same reckless choice. One is lucky, the other crashes. How are they assessed?
- The same, because it is the behaviour that is assessed, not the outcome
- The one who crashed is assessed more strictly
Answer: The same, because it is the behaviour that is assessed, not the outcome
- The same, because it is the behaviour that is assessed, not the outcome: Correct. Luck does not make the behaviour better, and bad luck does not make it worse.
- The one who crashed is assessed more strictly: No. That is outcome bias, from lesson 2.1.