Most accidents involve a series of minor errors
I was on a business trip, having completed a safety training session with managers and associates in an industrial plant the previous day. Preparing to head out to the airport, I called the front desk of my hotel to have my rental car brought around. I went down to the lobby, checked out, and waited for my car to be brought around … and waited….
After about 15 minutes, it occurred to me that the front desk might not have communicated with the valets. So I approached one of the valets, who told me after searching for my keys in a filing cabinet, “Someone must be bringing your car around now, because your key is not here”. So I waited another 10 minutes…
I talked to a different valet. This fellow asked me what kind of car it “was”… I told him it was a Nissan Maxima, and he asked “what color?” I told him it was silver. As he began reviewing the wall and wad of keys and tickets, he said “we have a black one and a gray one… are either of those yours?” I assured him that the rental car company probably would prefer that I return the actual car I rented from them.
Now 30 minutes into what should have been a five minute process, a woman at the desk came out and said, “The gentleman who has your car just called in, and he is about 20 minutes away, in traffic.”
So, they had given my rental car away.
A comedy of errors
How in the world did this happen!?
A very embarrassed man did in fact arrive in my rental car (he probably discovered his error when he tried to return my car to his rental company). I rushed to the airport, ran to my gate, got aboard just before the door closed, and finally relaxed and reflected on the comedy of errors I had just experienced. The scenario was not a sudden, deliberate, single-cause event. It was a chain of events, most of them fairly minor, all of them avoidable, which compounded and resulted in my car going to a stranger (and me going ballistic).
I always park my car myself when I have the option. But this downtown hotel did not have the self-park option. Valet parking was mandatory.
Second, I usually deal directly with valets when necessary, see them take my keys and ticket and see them bring my (actual) car. But not this time, because the hotel was very busy and I was told to call down ahead to have the valets retrieve my car.
The other fellow must have arrived in the lobby to get his car sometime after I had called but before I came down. The timing was “perfect.” He must have also called down early, thus expecting his car to be there when he got down. I assume he saw my car waiting, which I assume resembled his car.
I assume the valet did not check claim ticket numbers (violating SOP), and just gave my car to the man who said it was his, and who then got in and drove off. I assume my seat and mirror settings were like his, so the car didn’t “feel different” enough for him to realize this was not his car.
What a chain of unlikely events. It could have been pre-empted, or interrupted at any of a half dozen points. But it wasn’t.
The compound effect of minor errors
Think about a typical accident. Most conform to the same pattern as my frustrating but not injurious comedy of errors. It’s probably human nature to fear a sudden dramatic misfortune. I suspect people who have a phobic fear of flying fear a sudden massive mechanical failure quite a bit more than they do a chain of minor unlikely miscommunications and/or other errors between pilots. The former, while it does happen, is extremely uncommon; the latter, while infrequent overall, is much more common than the former.
My scenario is a vivid reminder of how accidents actually happen. They are most often the end point of a series of unlikely error-events, not the sudden “large-scale breakdown.”
The key take-away from my absurdly unlikely story? If any of the actors in that drama (especially the valet) had said, “wait a minute” and asked a good question, stopped a mindless act, corrected an error, there is no incident.
When things start to look and sound a bit off-normal, or if you are merely doing a routine task mindlessly, that’s the time to stop, step back… and interrupt the chain.