70
6 Justifying the Need for New Approaches
6.4.1 Human Factors
The use of a “human factors” framework to guide the IFT’s investigation of the
Oroville incident was very useful by helping to identify many of the factors that have
to be addressed or overcome in the establishment of a culture devoted to the highest
standards of risk identification and management. The approach adopted by the IFT
is described in detail in Appendix J of the IFT Report. Selected aspects of Appendix
J are summarized below.
Based on observations by the IFT of past failures, it is stated that “… failures—in
the sense of human intentions not being fulfilled—are fundamentally due to human
factors.” To protect against human failures, it is then observed that barriers, such
as factors of safety, are established which must be overcome for failure to occur.
From this it follows that those human factors that may contribute to failure must be
identified and addressed.
The primary drivers of failure are described as pressure from non-safety goals,
human fallibility and limitations and complexity. Complexity is described as:
…resulting from multiple system components having interactions which may involve nonlinearities, feedback loops, network effects, etc. Such interactions can result in large effects
from small causes, including “tipping points” when thresholds are reached, and they make
complex systems difficult to model, predict, and control… Complexity generally exacerbates
the effects of human fallibility and limitations.
It is then stated that, while the drivers of failure lead to various types of human
error, this:
…is not a sufficient endpoint for a forensic investigation. Instead, human errors should be
treated as prompts to investigate further and delve deeper, to understand the situational and
contextual factors which contributed to those human errors…That is the approach the IFT
endeavoured to take for this investigation.
With regard to risk management, the IFT states that the underlying primary drivers
of failure that often lead to inadequate risk management are primarily due to: (1) Ignorance—not being sufficiently aware of risks; (2) Complacency—being sufficiently
aware of risks but being overly risk tolerant; and/or (3) Overconfidence—being sufficiently aware of risks, over estimating ability to deal with them. While not stated as
such by the IFT, these factors are basically barriers to good risk management which
must be overcome.
The application of human factor methodology to the Oroville incident required
the consideration of a wide scope of factors and how they could have an impact on
judgments, decisions, actions, inactions, influencing situational factors, and interactions. In that the ITF’s finding with respect to human factors are presented in detail
in the main report, Appendix J presents an overview of some of the higher—level
human factors that contributed to the spillway incident. The observations pertaining
to the subject of this book are as follows:
The inadequacies in dam safety risk management that contributed to the failure primarily
involved ignorance about the existence of the risks associated with the spillways, which was
6 Justifying the Need for New Approaches
6.4.1 Human Factors
The use of a “human factors” framework to guide the IFT’s investigation of the
Oroville incident was very useful by helping to identify many of the factors that have
to be addressed or overcome in the establishment of a culture devoted to the highest
standards of risk identification and management. The approach adopted by the IFT
is described in detail in Appendix J of the IFT Report. Selected aspects of Appendix
J are summarized below.
Based on observations by the IFT of past failures, it is stated that “… failures—in
the sense of human intentions not being fulfilled—are fundamentally due to human
factors.” To protect against human failures, it is then observed that barriers, such
as factors of safety, are established which must be overcome for failure to occur.
From this it follows that those human factors that may contribute to failure must be
identified and addressed.
The primary drivers of failure are described as pressure from non-safety goals,
human fallibility and limitations and complexity. Complexity is described as:
…resulting from multiple system components having interactions which may involve nonlinearities, feedback loops, network effects, etc. Such interactions can result in large effects
from small causes, including “tipping points” when thresholds are reached, and they make
complex systems difficult to model, predict, and control… Complexity generally exacerbates
the effects of human fallibility and limitations.
It is then stated that, while the drivers of failure lead to various types of human
error, this:
…is not a sufficient endpoint for a forensic investigation. Instead, human errors should be
treated as prompts to investigate further and delve deeper, to understand the situational and
contextual factors which contributed to those human errors…That is the approach the IFT
endeavoured to take for this investigation.
With regard to risk management, the IFT states that the underlying primary drivers
of failure that often lead to inadequate risk management are primarily due to: (1) Ignorance—not being sufficiently aware of risks; (2) Complacency—being sufficiently
aware of risks but being overly risk tolerant; and/or (3) Overconfidence—being sufficiently aware of risks, over estimating ability to deal with them. While not stated as
such by the IFT, these factors are basically barriers to good risk management which
must be overcome.
The application of human factor methodology to the Oroville incident required
the consideration of a wide scope of factors and how they could have an impact on
judgments, decisions, actions, inactions, influencing situational factors, and interactions. In that the ITF’s finding with respect to human factors are presented in detail
in the main report, Appendix J presents an overview of some of the higher—level
human factors that contributed to the spillway incident. The observations pertaining
to the subject of this book are as follows:
The inadequacies in dam safety risk management that contributed to the failure primarily
involved ignorance about the existence of the risks associated with the spillways, which was