Engineering, Construction and Architectural Management 2002 9 1, 53±61
The pathology of building defects; a human error approach
ANDREW R. ATKINSON
Faculty of the Built Environment, South Bank University, 202 Wandsworth Road, London SW8 2JZ, UK
Abstract Research driven by major industrial and
transportation incidents is increasingly emphasizing the
role of managers and systems factors in errors. This is
re¯ected in recent reports and legislation which place
emphasis on managerial actions. This paper reports
research developing a human error perspective, but
applying it to lesser failures in the form of construction
defects. An observational study of a 61 unit housing site
con®rms ®ndings from earlier studies, that managerial
factors are important in the occurrence of defects, but
also that factors can be linked in a `causal chain'. Latent
INTRODUCTION
A number of major transportation accidents in recent
years, culminating in the Southall and Paddington rail
disasters of 1997 and 1999, has focused attention on
human errors. Yet of®cial reports of major incidents
have become increasingly unwilling to attribute blame
solely to the most obvious individual involved, whether
driver, pilot or helmsman. Instead, the importance of
managers is being increasingly emphasized and the
organizations providing transportation services are
being increasingly seen as systems, where the `front
line' crews are merely the most visible parts of large
co-operative efforts involving several separate compo-
nents. Recognition of the role of managers has resulted
in the UK in proposals for an offence of Corporate
Manslaughter and moves to further strengthen the
powers of the Courts to prosecute individual senior
managers. Current of®cial thinking in the UK had been
succinctly summarized as long ago as 1986 by Lord
Justice Sheen in commenting on the role of senior
managers in the report of the Herald of Free Enterprise
disaster (Department of Transport, 1987):
the underlying, or cardinal faults lay higher up the
company ¼. from top to bottom the body corporate
was infected with the disease of sloppiness.
More relevant to the construction industry is the enact-
ment of the Construction Design and Management
Regulations (HMSO, 1994), which imposes duties on
ã 2002 Blackwell Science Ltd
managerial errors are often hidden behind more obvious
operative errors, leading to incorrect attributions and
ineffective remedial action. The study also supports a
conceptual model of the nature of errors in construction
projects, which makes explicit the in¯uence of manage-
ment on the generation of defects and the need to treat
organizations as a whole in considering the reasons for
failure.
Keywords defects, error, management, participant
observation, systems
managers including the client, designer, principal
contractor and other contractors to ensure that organi-
zations involved adopt safe systems of working.
Incorporation of CDM requirements into contract
documents further strengthens the managerial role by
making breach of the statutory duty also a breach of
contract.
In fact, the movement towards recognizing the role of
managers in human error has been developing for some
considerable time. The Health and Safety at Work Act
of 1973 (HSE, 1973) imposes duties on managers with
respect to promoting safety and safe systems of working
and several authors, particularly with backgrounds in
psychology or sociology (Turner, 1978; Rasmussen,
1983; Lourens, 1990; Reason, 1990; Perrow, 1984)
have been emphasizing that human errors at the `work
face' are often inevitable and should be managed.
Reason (1990) proposed a `resident pathogen meta-
phor' in order to illustrate the role of managers, where
poor managerial controls have the effect of predisposing
a system to failure. It then only requires a small error by
a front-line worker to precipitate a major incident.
Thus, Reason divides errors into active and latent, active
errors precipitating the incident and latent errors being
the underlying managerial failing. This division of
causes into active/latent, operative/managerial or pri-
mary/secondary is echoed widely in other literature on
human factors (Fortune, 1984; Kletz, 1985; Petroski,
1985, 1994; Eldukair & Ayyub, 1991; Blockley, 1992;
Embrey, 1992; Whittington et al., 1992, Fortune &
53
54 Atkinson, A. R.
Peters, 1995), with some authors proposing more
complex models of human error based on the proximity
or remoteness of the cause from the outcome.
The unifying feature of the literature is that it relates to
fairly large scale disasters and accidents usually involving
death. The primary concern of the authors is public
safety, or the safety of industrial workers. Yet interesting
parallels are made in some literature between safety and
quality (Whiston & Eddeshaw, 1989; Harrison, 1992;
Whittington et al., 1992; ACSNI, 1993; Oakland,
1998). This suggests that much can be learned from
recent thinking on human error about the performance
of tasks with less dramatic outcomes. Nonetheless, the
construction industry generally has been slow to expli-
citly recognize the importance of human factors in the
generation of defects. In a construction industry context,
the `pathology of defects' is normally taken to mean the
underlying technical cause and not the sequence of events
leading to an error being committed. This is re¯ected in
a literature on defects obsessed with the details of
`correct' technology (Department of the Environment,
1989; BRE, 1991; HAPM, 1991), although that tech-
nology is hardly novel. In other words, the industry has
been slow to recognize that the problem with defects is
not so much a matter of not knowing what to do, but
applying correctly what is known (Kletz, 1985; Bea,
1994). There have been some intermittent attempts to
examine the error related causes of defects, for example,
by the UK Building Research Establishment (Bentley,
1981; Bonshor & Harrison, 1982; Harrison, 1993), but
these appear to be unable to get beyond apportioning
errors between `site' and `design', and do not clearly
indicate how or why they occur.
A HUMAN ERROR PERSPECTIVE
The research reported in this paper is the ®nal of a
series of investigative studies which build on recent
theories of human error. The studies combine quan-
titative and qualitative methodologies, progressively
narrowing the focus of investigation from a general
survey of participants in the construction industry,
through a statistical study of several construction pro-
jects and an interview study of managers in the indus-
try to the current study ± a participant observation
study of one construction site. Taking as a starting
point literature drawn from three major perspectives,
technological (Petroski, 1985, 1994; Kaminetzky, 1991),
social science (Perrow, 1984; Reason, 1990; Roberts,
1993) and management (Embrey, 1992; ACSNI, 1993;
Morris, 1994), a tentative conceptual model of how
the error process might operate in complex project
systems was constructed and is illustrated in Fig. 1.
ã 2002 Blackwell Science Ltd, Engineering, Construction and Architectural Management 9 1, 53±61
Figure 1 Model of the nature of error in projects.
The model is constructed as a series of concentric
rings and shows errors with most immediate effect at
the centre and more remote factors towards the edge.
Thus, Primary errors are those committed `at the work-
face', often, but not exclusively, by manual operatives.
Of more remote, but wider effect are errors committed
at the project level, classed in the model as `manager-
ial'. The literature suggests ®ve categories of manager-
ial error related to checking work, division of
responsibilities, control of change, control of concurrent
working and communications. `Global' factors in¯uence
the project environment yet more generally and
include both factors operating within an organization
(described in the model as global/organizational ) and
wider economic, time, political and societal pressures
(described in the model as global/environmental). For
some global categories, for example, time, classi®cation
between `organizational' and `environmental' is dif®-
cult. Time pressures might be imposed externally, by
clients, or internally by senior managers for corporate
reasons. For this reason, categorization at this level
should be treated as tentative and variable. Not
speci®cally illustrated by the model are the linkages
between categories. For example, errors occurring in
one category are in¯uenced by other pressures else-
where in the `project system'. It is these linkages,
which are more dif®cult to detect with the commonly
used research techniques of statistical analysis and
formal interviews, that are focused on in the observa-
tional study reported below.
The model adopted a similar structure to several
developed in the literature. For example, Embrey
(1992) categorized accident causation in process
industries into three `levels', actual errors, error inducing
factors and higher level policy factors and Whittington
et al. (1992) postulated a hierarchical model for
construction accidents, which operated on four levels,
that of the individual, site management, project manage-
ment and company policy. However, these models were

largely drawn from literature, without further empirical
investigation. The current research sought to empiric-
ally investigate three properties of the model illustrated
in Fig. 1, its form, content and operation.
PREVIOUS WORK
An initial general survey (reported in detail in Atkinson,
1998) was directed towards examining the form and
content of the model. It consisted of a survey of
approximately 100 construction industry practitioners.
Survey respondents were presented with a question-
naire asking them to rate factors in the model and to
supply further factors they considered important.
Communications was the highest rated factor, followed
by time pressures, avoiding concurrency controlling
changes and education and training. Lower rated factors
were those relating to political, economic and societal
pressures. The three-level form of the model was
examined by using factor analysis. Although the `®t'
was not perfect, the results showed a fairly clear split
between factors, such as economic, societal and poli-
tical pressures `outside' the control of project partici-
pants and factors `within' their control.
A follow-up statistical study, reported in Atkinson
(1999), was also directed towards the content of the
model. It investigated whether there was any statisti-
cally signi®cant relationship between variables repre-
senting factors in the model and the level of defects in
23 speculatively built housing projects in the South-
east and Midlands regions of the UK. In addition to
the factors directly included in the model, the in¯uence
of primary factors, but at the ®rst key level of
management (the site manager) were represented by
adding variables representing the experience, background
and quali®cations of the manager. Signi®cant results
were concentrated on tangible managerial factors
including the level and quality of formal communica-
tions. However, signi®cant associations were also
revealed between primary factors at a managerial level
and defects. A particularly interesting ®nding was an
`inverse' association between the experience of the site
manager and the level of defects, with less experienced
managers performing better. A further statistical test
revealed that inexperienced managers are also better
quali®ed, suggesting that quali®cations more than
make up for lack of experience.
In order to investigate how an error at a managerial
level might in¯uence errors at the work-face the statis-
tical study was followed by interviews. A total of 40
managers in the house-building industry were inter-
viewed and the notes from the interviews were subjec-
ted to content analysis (Crano & Brewer, 1973). In total
ã 2002 Blackwell Science Ltd, Engineering, Construction and Architectural Management 9 1, 53±61
The pathology of building defects 55
220 error `instances' were examined and communications
problems again overwhelmingly predominated. These
were again mainly centred on formal communications,
such as poorly communicated speci®cations, drawings
and written instructions. Analysing the accounts of the
causes of defects revealed links between factors in the
model in the form of interactions. These were classi®ed
in three categories, simple self contained errors, two-way
interactions and complex interactions. Two-way interac-
tions involved two factors, often a combination of poor
operative work and poor supervision. For complex
interactions, a further two pathologies were identi®ed.
First, some errors were initiated at a point in the
construction chain and `carried through' the construc-
tion process and/or replicated elsewhere because of
poor communications and supervision. Secondly, some
systemic multiple errors were `driven from the top' by
wider corporate considerations, such as meeting year
end accounting periods. These were not really `errors'
at all, but deliberate actions to achieve goals not related
to defects.
THE OBSERVATIONAL STUDY
The observational study allowed direct examination
of the incubation of potential building defects. It
involved participant observation, by the author, of one
construction site for a short period of time. The site
chosen was one of the housing sites which formed part
of the earlier statistical study. The time point chosen
for the study within the life cycle of the project was
when most construction activities were taking place
(from excavating foundations to completing buildings)
and one of the advantages of traditional two of three
storey housing is that it is common for all phases to be
under construction at the same time. The time scale
chosen for the study was 1 week. This was considered
to be the minimum time for a cross-section of events
to be evidenced suf®ciently to compliment other parts
of the research. It was considered that signi®cant
events related to incipient and actual errors on the
project would be visible from the vantage point of the
site and the site of®ce for this type of construction.
Problems arising on site were likely to be reported
regularly to the site of®ce as managerial control was
centralized there. The site consisted of 61 two, four
and ®ve bedroom terraced and detached houses
marketed towards both the `®rst-time buyer' and
`executive' markets. Traditional construction was
used with brick/block walls, interlocking concrete
tiled roofs, timber windows and timber ¯oor and
roof construction. The researcher attempted to integ-
rate into the operations of the site by volunteering to
56 Atkinson, A. R.

carry out tasks required by the site managers through-

out the week. In particular, he volunteered to answer
the telephone, because the site telephone was thought
likely to be the hub of communication activities.
Integration was fairly successful in that, during the
study period, the researcher was given several clerical
tasks and asked to assist in solving several site-based
problems in relation to changes in construction details.
Nevertheless, the effect of the observer on the study
cannot be discounted. In dealing with this effect, one
of the strengths of the overall research programme is
that any distortion caused by the presence of the
observer for this study is reduced when ®ndings from
all studies are combined. A process of `triangulation'
can be used to improve con®dence in the overall Figure 2 Record of error instances.
conclusions from the programme.
Data were recorded by writing timed entries in a
Instances of error
rough note book during, or as soon as possible after, the
occurrence of an event, following a standard methodo- Direct observation and discussions on the site were
logy for diary studies (Coolican, 1994). All events were transferred to a formal transcript at the end of the
reviewed at the end of each day and contemporary study. This included an analysis of the cause(s) of the
notes were added. The entries and commentary were incident recorded, contemporary comment and com-
then transcribed for later analysis. ment added on completion of the study. Following the
Although not the primary purpose of the study, a categorization adopted in the model, incidents of errors
numerical analysis of the source of errors was under- were extracted and examples in the form of short
taken to see if the results con®rmed earlier work. vignettes are given below:
Following Bentley (1981) the text of the diary was
analysed into a number of `error related events'. Such
Primary errors
events were problems reported and discussed in the site
of®ce, instances of actual errors occurring on the site, Relatively few recorded instances related to primary
or tactics used to avoid errors occurring. Coding of factors, but of those that did occur, a prominent
instances to particular factors in the model was then example was a violation by operatives placing concrete
carried out and are shown in Table 1 and Fig. 2. foundations to a series of houses. This was witnessed
Managerial factors predominated in the occurrence of by a building inspector from a building guarantee
defects, followed by global factors and lastly primary. insurance company, who was on the site at the time.
The importance of managerial factors resonates strongly He observed one operative adding water to the concrete
with the earlier studies. as it was unloaded from the mixing lorry, an action
carried out to improve the `¯ow' and hence the
workability of the concrete, but an action which would
Table 1 Record of error instances. also reduce its strength. The inspector refused to
approve the concrete without further evidence (provi-
Factor in the model Recorded instance ded later) that the strength of the concrete was
Primary 8 adequate. Closer supervision might have reduced the
Managerial scope for this violation, but as it was clearly a deliberate
Checking 5 act, it would be dif®cult to stop unless supervision was
Communications 22 continuous or unless other action were taken such as a
Concurrency 3
bonus or training scheme emphasizing the importance
Changes 12
Responsibility division 1 of proper procedures.
GLOBAL ± Organizational 6 Other instances could not be clearly attributed to
GLOBAL ± Environmental primary error. For example, one decorator was accused
Time 2 of applying the wrong wallpaper to the wrong rooms in
Cost 13
a show-house. This could have been a primary error by
Societal 6
an operative, but could equally have been an error in

ã 2002 Blackwell Science Ltd, Engineering, Construction and Architectural Management 9 1, 53±61

communications if clear drawings or instructions had
not been given. As communications in this case were
verbal, it was almost impossible to prove whether
instructions had, in fact, been given.
In a further instance, the `real' cause of an error may
have been masked by a primary error, thus also making
accurate attribution dif®cult. This instance was that of
a carpenter cutting ¯oor timbers to an incorrect size.
Alterations to one unit (plot 34) on the site induced by
bespoke changes made for a purchaser had increased
the span of the ¯oor timbers. Consequently, the
carpenter used timbers destined for another unit.
Only after he had cut these to the correct length did
the carpenter realize that the depth of the timbers was
insuf®cient and would then have to be discarded. In
this instance, not only was the underlying cause of the
carpenter's error an uncontrolled change, but behind
the change was economic forces and societal demands,
which required the organization to allow purchaser
customization.
An examination of the external building inspector's
site ®le revealed similar ambiguities. Most defects
reported in this ®le were related to what were ostensibly
minor workmanship errors ± for example, poor bonding
of brick to block walls, concrete ®lling to cavity walls in
foundations being incorrectly placed and insuf®cient
allowance in external brickwork for weep-holes over
openings and ventilators below ¯oors. However, it is
not at all clear how much knowledge of construction
technology was expected from the operatives con-
cerned. With high expectations, the errors are primary
in nature and should be attributed to the operative.
However, modern industry often cannot have such high
expectations of its workforce and the need and nature
of construction details must be clearly communicated to
the operative and checked for inclusion. Thus, errors
can be classi®ed as primary or managerial depending on
the expectations of the organization ± expectations
which were, on this site, not made clear.
Managerial errors
Instances related to problems with formal and informal
communications were common during the study. One
example related to the circuitous routing of payment
cheques at company level. The site manager had
continually requested that the electricity and water
companies be paid, so that supplies could be laid on for
both temporary use by the workforce and for the
permanent installation. However, large cheques, such
as the ones involved in this incident, were deliberately
routed through senior company management in order to
give centralized ®nancial control. Senior management
ã 2002 Blackwell Science Ltd, Engineering, Construction and Architectural Management 9 1, 53±61
The pathology of building defects 57
were physically located separately from the regional
company of®ce, thus lengthening communication
chains. Hence, there was a delay in authorization. To
keep to time, operatives were required to instal perma-
nent plumbing and cabling without the opportunity for
tests prior to these being covered by subsequent work.
Although not necessarily causing defects, the inability
to test installations would certainly pre-dispose them to
failure ± an illustration of the operation of Reason's
(1990) resident pathogen metaphor.
Other communications problems included numerous
errors in speci®cations, schedules and drawings and
lack of, or poor, communication of information. In one
instance, the layout on the foundation drawings did not
match that on the superstructure drawings and work on
the superstructures had actually commenced. A con-
siderable amount of masonry had to be re-built to
correct this error.
Change was also regularly implicated as a cause of
potential and actual errors. One of the most prominent
agents inducing change was the facility (mentioned
above) for the house purchaser to make adaptations to
their prospective purchase. This was not well controlled
and in some instances purchasers were allowed to make
changes after work had started, leading to the need to
dismantle work. One small example of this was where a
purchaser asked for a smaller external door in a unit,
but the operatives were not informed of this. The
opening had to be reduced in size after it had already
been formed. In the incident reported above concern-
ing a carpenter's error, the house purchaser had asked
for a wall to be moved, but little consideration had been
given to the consequences of this request.
Problems of concurrency were noted, but generally
as a consequence of other failings. For example,
problems related to the installation of electrical and
water mains caused by cost factors were leading to the
concurrent installation of electrical and plumbing
services with the installation of the mains, rather than
the sequential installation of mains followed by services.
Global errors
Instances related to organizational culture featured
on several occasions during the study. In meetings
between site sales and construction staff, a cultural `gap'
between site and head of®ce personnel was apparent. A
con¯ict of cultures was illustrated by the differing
orientations of top management and construction man-
gers over the organization of and payment for services
installations mentioned above. A further example of a
cultural `gap' was related to the need to re-site the
temporary site of®ce and sales cabin to allow the
58 Atkinson, A. R.
construction of one of the houses. The site manager was
trying to gain authorization for a large crane to carry out
this manoeuvre, as this would be both more convenient
and safer. However, the company commercial manager
was refusing on cost grounds. This incident illustrated a
common con¯ict between operational and ®nancial
considerations, which impact on both quality and safety.
Global factors of cost time and societal demands were
seen by site personnel as being behind many of the
problems experienced with the project. This was
particularly the case with the facility for purchasers to
order changes to their houses. Here the site managers
saw problems of a `tight' economic climate leading to
purchasers demanding more in the way of changes, but
the company failing to respond adequately. Similarly,
tight costs, driven by economic pressures were perceived
to underlie the lack of services installations. Non-
payment of the bill for the electrical main was linked
to ®nancial year-end cash ¯ow requirements, in turn
driven by an external threat of corporate take-over.
ERROR PATHOLOGY AS A `SYSTEM'
Instances arising from the observational study, inclu-
ding those chronicled above, illustrate the `systemic'
nature of error in¯uences where one cause of error
might be linked to others and thus in¯uence the
eventual outcome. Three attributes of this `systems'
effect were noted, multiple causes of error, causal paths
and hidden or latent characteristics.
Multiple causes and consequences of error
An example of multiple causes/consequences of error
was related to the problem with the supply of services
to the site mentioned above. At the time of the
study, neither an electrical nor a water supply had
been provided and the lack of an electrical supply
pre-disposed construction to errors (electrical instal-
lations could not be tested, houses could not be han-
ded over to purchasers and electricity was required
for may of the internal activities in ®nishing the
houses). The lack of supply was caused by at least
three factors:
· Failure of the company to pay the electricity board
for the supply (in turn caused by long communi-
cation lines and the need to conserve cash at the
company's accounting year-end).
· Failure to agree with the position of an electrical
sub-station with house-builders on adjoining sites.
· Failure to organize town planning approval for the
same sub-station.
ã 2002 Blackwell Science Ltd, Engineering, Construction and Architectural Management 9 1, 53±61
Causal paths
The causal path of errors can be traced with the
example related to the facility for prospective purchasers
to have adaptations carried out to their houses. This led
to a number of problems based on the fact that the
manager agreeing to the changes was not competent to
assess technical feasibility. For example, agreements to
move the position of walls led to upper ¯oor timbers
being over-spanned, thus pre-disposing the ¯oor to
collapse. Similarly changing an internal garage to a
habitable room induced problems with town and
country planning approvals. The facility for purchasers
to make very late changes to their houses was driven by
slow sales caused by a poor economic climate. The
`causal path' of error in¯uences is traceable from
economic in¯uences to increased societal demands to
changes inducing concurrent working and thence primary
errors.
Hidden or latent characteristics
The facility of purchasers to change details of house
layouts also illustrates the latent nature of some errors.
In the incident of the carpenter cutting up the wrong
¯oor timbers, the pathology of this error started with a
change requested by a purchaser which had the effect of
lengthening the span of ¯oor timbers. Had the carpen-
ter used the timbers, the `error' would have appeared
later as his alone although it had more to do with an
insuf®ciently controlled change at the managerial level.
In the event, it is notable that the operative effectively
spotted and corrected the mistake. This illustrates
another characteristic of latent errors ± they are often
capable of correction by the operatives carrying out
work.
CONCLUSIONS
The observational study supports earlier ®ndings in
the research programme. By triangulating between
studies, some clear conclusions can be drawn. The
importance of managerial errors, and those in partic-
ular related to communications, is con®rmed. In itself,
this ®nding appears unremarkable, but communication
failures speci®cally noted in the observational study
and earlier studies often pointed to poor formal
communications. Poor formal communications did
not solely concern errors in documents, but also
concerned the transfer and use of information. The
problem was not, therefore, simply one of mistakes in
design or speci®cation. Traditionally, house-building
in the UK has operated with a minimum of formal

communications and reliance has been placed on the
skills of both operatives and site management. The
®nding that poor formal communications are to blame
for many errors potentially leading to defects suggests
that this traditional reliance might now be outdated.
The combination of a more complex technology, even
for traditionally built housing, and a workforce with
very basic construction technology skills suggests that
greater effort should be made to provide and commu-
nicate documentation. The balance mentioned above,
between the internalized knowledge of the operative
and that expressly provided by way of drawings and
details, should be re-examined. Even the act of provi-
ding and communicating better constructional details
illustrates the complex interaction of factors leading to
errors. In the short term, more comprehensive docu-
mentation has a negative cost and time implication
and this might be resisted by managers with other
corporate objectives.
The observational study also illustrates links between
factors at different levels in the model. Complex
interactions identi®ed in the earlier interview study
are con®rmed, in particular the fact that underlying
errors are often disguised by subsequent primary errors
committed by work-face operatives. The operative can
also act as a `modulating' in¯uence, correcting errors
committed by managers. The model conceptualized in
Figure 3 The pathology of error in projects.
ã 2002 Blackwell Science Ltd, Engineering, Construction and Architectural Management 9 1, 53±61
The pathology of building defects 59
Fig. 1 does not illustrate linkages and an alternative
conceptualization is given in Fig. 3 below. This illus-
trates how errors have been seen to develop in the
study into actual or potential defects. Often driven by
global pressures, unrelated to the project, managerial
errors either combine with or supplement operative
errors to cause defects. The ®gure shows how errors
by managers may be `modulated' by the actions of the
operative and the unwanted outcome may be avoided.
The ®gure also shows that errors can arise at all levels
of the model.
The consequence of accepting the ®ndings from this
study is that in both analysing the cause of events
(whether defects, failures or major accidents)
and in proposing avoiding action, the organization
(whether a project, or an incorporation) has to be
treated as a whole. This conclusion resonates remark-
ably with the teachings on quality management of W
Edwards Deming nearly half a century ago (Tenner &
DeToro, 1992). Deming made the distinction between
special causes of failure, assignable to operators, and
common causes, the responsibility of managers.
Deming stressed that common causes predominate,
that it is the system of work that determines how work
is performed and only senior managers can create
the system. Arriving at the same conclusion from the
starting point of human error indicates that the
60 Atkinson, A. R.
main factor linking quality, safety and business
performance is management. Developing systems of
management, which tackle in detail the sources of
errors documented here should lead to considerable
reductions in defects, but may also reduce accidents
and improve pro®tability.
A note on methodology
Participant observation is a technique seldom used in
construction management research and, where used
elsewhere, is often associated with an interpretivist
perspective based on a relativist ontology. This study
shows that methodology is not necessarily related
to epistemology. Qualitative techniques are valuable
in investigative research attempting to establish cause
[and hence based on a realist ontology (Sayer, 1992;
Hammersley, 1992)]. Criticisms of the technique usua-
lly centre on an inability to generalize from the
observed situation, but attempts to make research in
construction management generalizable by using wider
statistically based studies often struggle to establish the
link between cause and effect. Confounding variables
and dif®culties in containing concepts in measurable
dependent and independent variables contribute to
this dif®culty. Providing suitable precautions are taken
to integrate the participant and verify his/her observa-
tions, participant observation has the over-riding
advantage of revealing events `as they happen', with
the possibility of uncovering more accurately the causes
and consequences of actions. In complex environments
such as construction sites, this possibility is worth
notional loss of generalizability. An example of the
potential of participant observation is provided (in the
negative) by the counter-intuitive ®nding from the
earlier statistical study that less experienced, but better
quali®ed site managers are less prone to make errors.
The statistical study was unable to determine the
reason for this ®nding, but an organized observational
study might be able to detect patterns of behaviour
explaining it. As this was not done, one is left to
speculate!
The generalizability of ®ndings from observational
studies can be widened by using several studies,
replicating earlier work by others, or by using compli-
mentary studies based on other techniques. The study
reported here relies on triangulation with compliment-
ary studies to improve con®dence in the ®ndings.
Con®dence could be further improved by increasing
the number of observations, which is most easily done
by increasing the duration of the study, and by
increasing the number of observers so that differences
in recorded observations can be controlled.
ã 2002 Blackwell Science Ltd, Engineering, Construction and Architectural Management 9 1, 53±61
REFERENCES
ACSNI (1993) Advisory Committee on the Safety of Nuclear
Installations ± Study Group on Human Factors Third Report:
Organising for Safety. HMSO, London.
Atkinson, A.R. (1998) Human error in the management of
building projects. Construction Management and Economics,
16, 339±349.
Atkinson, A.R. (1999) The Role of Human Error in Construction
Defects. Structural Survey, 17/4, 231-236. MCB University
Press, Bradford, UK.
Bea, R.G. (1994) The Role of Human Error in Design, Con-
struction and Reliability of Marine Structures. US Ship Struc-
ture Committee (National Technical Information Service),
Spring®eld, VA, USA.
Bentley, M.J.C. (1981) Quality Control on Building Sites.
Building Research Station Current Paper 7/81. Building
Research Establishment, Watford, UK.
Blockley, D.I. (ed.) (1992) Engineering Safety. McGraw-Hill,
New York.
Bonshor, R.B. & Harrison, H.W. (1982) Traditional Housing:
A BRE Study of Quality. Building Research Establishment
Information Paper 18/82. Building Research Establishment.
Building Research Establishment (BRE) (1991) Housing
Defects Reference Manual ± The Building Research Establish-
ment Defects Action Sheets. E and F N Spon, London, UK.
Coolican, H. (1994) Research Methods and Statistics in Psy-
chology. Hodder and Stoughton, London.
Crano, W.D. & Brewer, M.B. (1973) Principles of Research in
Social Psychology. McGraw-Hill, New York, quoted in
Coolican (1994).
Department of the Environment (1989) Property Services
Agency, Directorate of Building and Development, Defects in
Building. HMSO, London.
Department of Transport (1987) Herald of Free Enterprise
Formal Report. HMSO, London.
Eldukair, Z.A. & Ayyub, B.M. (1991) Analysis of recent US
structural and construction failures. Journal of Performance of
Constructed Facilities, 5, 57±73.
Embrey, D.E. (1992) Incorporating management and organ-
isational factors into probabilistic safety assessment. Reli-
ability Engineering and System Safety, 38, 199±208.
Fortune, J. (1984) Complexity, Management and Change:
Applying a Systems Approach, Block 2, A Systems Approach
to Failures, Unit 7, Studying Systems Failures. Open Univer-
sity Technology Course T301. Open University, Milton
Keynes, UK.
Fortune, J. & Peters, G. (1995) Learning from Failure. The
Systems Approach. Wiley, London.
Hammersley, M. (1992). What's Wrong with Ethnography.
Routledge, London.
Harrison, P.I. (1992) Organisational, Management and
Human Factors in Quanti®ed Risk Assessment. Report
Nr2. HSE Contract Research Report Nr34/1992. HMSO,
London.
Harrison, H.W. (1993) Quality in New-Build Housing. Building
Research Establishment Information Paper 3/93. Building
Research Establishment.
Health and Safety Executive (1973) Committee on Safety and
Health at Work (Robens Committee) Safety and Health at
Work. HMSO, London.
HMSO (1994) The Construction (Design and Management)
Regulations. HMSO, London.

Housing Association Property Mutual Ltd. (HAPM) (1991) ±
Construction Audit Ltd., Defects Avoidance Manual (New
Build). Building Research Establishment.
Kaminetzky, D. (1991). Design and Construction Failures ±
Lessons from Forensic Investigations. McGraw-Hill, New York.
Kletz, T.A. (1985) An Engineer's View of Human Error. Institute
of Chemical Engineers, London, UK.
Lourens, P.F. (1990) Theoretical perspectives on error analysis
and traf®c bahaviour. Ergonomics 33 Nr, 10, 1251±1263.
Morris, P.W.G. (1994) The Management of Projects. Thomas
Telford, London, UK.
Oakland, J.S. (1998) Total Quality Management ± The Route
to Improving Performance. Butterworth±Heinemann,
London, UK.
Perrow, C. (1984) Normal Accidents. Basic Books, New York.
Petroski, H. (1985) To Engineer is Human. The Role of Failure in
Successful Design. Macmillan, New York.
Petroski, H. (1994) Design Paradigms ± Case Histories of Error
and Judgement in Engineering. Cambridge University Press,
Cambridge.
ã 2002 Blackwell Science Ltd, Engineering, Construction and Architectural Management 9 1, 53±61
The pathology of building defects 61
Rasmussen, J. (1983) Skills, Rules, Knowledge: Signals, Signs
and Symbols and Other Distinctions in Human Performance
Models. IEEE Transactions: Systems, Man and Cybernetics,
quoted in Reason (1990). SMC, 13, 257±267.
Reason, J. (1990) Human Error. Cambridge University Press,
Cambridge, UK.
Roberts, K.H. (1993) New Challenges to Understanding
Organisations. Macmillan, New York.
Sayer, A. (1992) Method in Social Science; A Realist Approach,
2nd edn. Routledge, London, UK.
Tenner, A.R. & DeToro, I.J. (1992) Total Quality Manage-
ment. Addison-Wesley, Reading, MA, USA.
Turner, B.A. (1978) Man Made Disasters. Wykeham, London.
Whiston, J. & Eddeshaw, B. (1989) Quality and safety ± dis-
tant cousins or close relatives? The Chemical Engineer, June
Nr, 461, 97±102.
Whittington, C., Livingston, A. & Lucas, D.A. (1992) Research
into Management, Organisational and Human Factors in the
Construction Industry. HSE Contract Research Report Nr
45/1992. HMSO, London, UK.