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" Valujet flight 592 crashed after takeoff from Miami airport because oxygen generators in its cargo hold caught fire. The generators had been loaded onto the airplane by employees of a maintenance contractor, who were subsequently prosecuted. The editor of Aviation Week and Space Technology “strongly believed the failure of SabreTech employees to put caps on oxygen generators constituted willful negligence that led to the killing of 110 passengers and crew. Prosecutors were right to bring charges. There has to be some fear that not doing one’s job correctly could lead to prosecution.”13 But holding individuals accountable by prosecuting them misses the point. It shortcuts the need to learn fundamental lessons, if it acknowledges that fundamental lessons are there to be learned in the first place. In the SabreTech case, maintenance employees inhabited a world of boss-men and sudden firings, and that did not supply safety caps for expired oxygen generators. The airline may have been as inexperienced and under as much financial pressure as people in the maintenance organization supporting it. It was also a world of language difficulties—not only because many were Spanish speakers in an environment of English engineering language: “Here is what really happened. Nearly 600 people logged work time against the three Valujet airplanes in SabreTech’s Miami hangar; of them 72 workers logged 910 hours across several weeks against the job of replacing the ‘expired’ oxygen generators—those at the end of their approved lives. According to the supplied Valujet work card 0069, the second step of the seven-step process was: ‘If the generator has not been expended install shipping cap on the firing pin.’ This required a gang of hard-pressed mechanics to draw a distinction between canisters that were ‘expired’, meaning the ones they were removing, and canisters that were not ‘expended’, meaning the same ones, loaded and ready to fire, on which they were now expected to put nonexistent caps. Also involved were canisters which were expired and expended, and others which were not expired but were expended. And then, of course, there was the simpler thing—a set of new replacement canisters, which were both unexpended and unexpired.”14 These were conditions that existed long before the Valujet accident, and that exist in many places today. Fear of prosecution stifles the flow of information about such conditions. And information is the prime asset that makes a safety culture work. A flow of information earlier could in fact have told the bad news. It could have revealed these features of people’s tasks and tools; these longstanding vulnerabilities that form the stuff that accidents are made of. It would have shown how ‘human error’ is inextricably connected to how the work is done, with what resources, and under what circumstances and pressures. "
― , Field Guide to Understanding Human Error
