Supervision
Recall that in addition to those causal factors
associated with the pilot/operator, Reason (1990)
traced the causal chain of events back up the supervisory chain of command. As such, we have identified
four categories of unsafe supervision: inadequate
supervision, planned inappropriate operations, failure to correct a known problem, and supervisory
violations (Figure 4). Each is described briefly below.
Inadequate Supervision. The role of any supervisor
is to provide the opportunity to succeed. To do this,
the supervisor, no matter at what level of operation,
must provide guidance, training opportunities, leadership, and motivation, as well as the proper role
model to be emulated. Unfortunately, this is not
always the case. For example, it is not difficult to
conceive of a situation where adequate crew resource
management training was either not provided, or the
opportunity to attend such training was not afforded
to a particular aircrew member. Conceivably, aircrew
coordination skills would be compromised and if the
aircraft were put into an adverse situation (an emergency for instance), the risk of an error being committed would be exacerbated and the potential for an
accident would increase markedly.
In a similar vein, sound professional guidance and
oversight is an essential ingredient of any successful
organization. While empowering individuals to make
decisions and function independently is certainly
essential, this does not divorce the supervisor from
accountability. The lack of guidance and oversight