As a law enforcement agency, men and women of the Coast Guard tend to think of violations as any departure from binding law or regulation. While planning errors of the violation type may in fact relate to legal violations, marine investigators should not confuse the two while conducting human error analysis. Planning errors of the violation type are deliberate decisions to break established rules, plans, or procedures. In some cases (but not all), those established rules, plans, or procedures have the force of law (ex: regulations, lawful orders, etc.). This section describes the most commonways in which people deliberately break rules, plans, or procedures.

　

Definition "Sabotage is deliberately violating a rule, law, regulation, or work practice with the knowledge that and explicit purpose of causing damage. In other words, the person commits a malevolent act." [Reason:195-6]

Example: Engineers aboard the M/V ROTTERDAM, faced with maintenance problems generating large volumes of oily bilge water, decided to build a pipe that bypassed the oily water separator and discharged the oily bilge water directly overboard, which is a knowing discharge of oil into the waters of the United States and is, therefore, a criminal offense. The engineers were willing to violate these laws because their pay was based on keeping maintenance costs down in the engine room, and excessive operation of the oily water separator would have enormously inflated spare part costs (and driven bonuses down dramatically).

Summary: The defining characteristic of sabotage is that the intent is to cause damage.

　

Definition: "Routine violations happen everyday as people regularly modify or do not strictly comply with work procedures, often because of poorly designed or defined work practices. Two factors seem important in shaping a person's routine violation behavior (a) the natural human tendency to take the path of least effort; and (b) a relatively indifferent or forgiving environment. In everyday life, if the quickest and easiest way to do something involves violating an apparently trivial rule or procedure that is rarely enforced/sanctioned, people will routinely violate that rule. The presence of this type of violation often indicates that the system itself could be better designed, keeping the operator in mind." [Reason: 196]

Example: Because landscape architects routinely lay out garden and park walkways on aesthetic grounds rather than according to how people will use the paths, people routinely violate the "stay on the paths" rule in order to walk the most direct route, leaving muddy diagonal tracks across the protected grassy areas.

Summary: The defining characteristic of routine adaptation is that: i) there is an easier action to take than the prescribed action; ii) it is done with some frequency; and iii) the environment is forgiving.

　

Definition: "In contrast to routine violations, an exceptional violation tends to be a one-time breach of a work practice. Typically these less defined types of violation result from "system double-binds" where it is impossible to follow one rule or procedure without violating another." [Reason: 196]

Example: At the Chernobyl site, safety regulations were deliberately ignored and a safety test was carried too far, ultimately resulting in disaster. However, the goal of violating the safety regulations was not to commit a malevolent act, but actually to improve system safety through the test.

Summary: The defining characteristic of exceptional adaptation is that: i) it is the product of local conditions; ii) they are very infrequent; and iii) the goal is to improve the situation.

In the final step of analyzing human error, the marine investigator considers the preconditions (related to the person) from the Causal Analysis (see Enclosure 2) that caused the unsafe act or decision itself. The many factors weighing on the person will have been detected, recorded, and organized during fact-finding using the SHEL model (see Enclosure 1). In practice, however, the marine investigator must direct considerable attention to explaining in the Conclusions (see Overview) how one or many of the SHEL factors caused the human error.