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 Investigating
Human Error
Incidents, Accidents, and
Complex Systems
Second Edition
 Investigating
Human Error
Incidents, Accidents, and
Complex Systems
Second Edition

Barry Strauch
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742

© 2017 by Taylor & Francis Group, LLC

CRC Press is an imprint of Taylor & Francis Group, an Informa business

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Library of Congress Cataloging-in-Publication Data

Names: Strauch, Barry, author.

Title: Investigating human error : incidents, accidents, and complex systems /
Barry Strauch.
Description: Second edition. | Boca Raton : Taylor & Francis, a CRC title,
part of the Taylor & Francis imprint, a member of the Taylor & Francis
Group, the academic division of T&F Informa, plc, [2017] | Includes
bibliographical references and index.
Identifiers: LCCN 2016041252| ISBN 9781472458681 (pbk. : acid-free paper) |
ISBN 9781472458650 (hardback) | ISBN 9781315589749 (ebook)
Subjects: LCSH: System failures (Engineering) | Accident investigation. |
Human engineering. | Aircraft accidents--Investigation. |
Aeronautics--Human factors.
Classification: LCC TA169.5 .S74 2017 | DDC 363.12/065--dc23
LC record available at https://lccn.loc.gov/2016041252

Visit the Taylor & Francis Web site at

http://www.taylorandfrancis.com
and the CRC Press Web site at
http://www.crcpress.com
This book is dedicated to the memory of Howard B. Brandon, Jr.

1982–2016
Contents

Foreword to Second Edition.................................................................................xv

Foreword to First Edition.................................................................................... xxi
Preface to Second Edition................................................................................ xxvii
Preface to First Edition...................................................................................... xxix
Author................................................................................................................xxxiii

1. Introduction......................................................................................................1
Introduction.......................................................................................................1
The Crash of ValuJet Flight 592.......................................................................2
Investigating Error............................................................................................5
Outline of the Book...........................................................................................6
References..........................................................................................................8

Section I Errors and Complex Systems

2. Errors, Complex Systems, Accidents, and Investigations..................... 13

Operators and Complex Systems.................................................................. 13
Complex Systems....................................................................................... 14
Operators..................................................................................................... 15
Normal Accidents and Complex Systems.............................................. 15
Human Error................................................................................................... 17
Theories of Error............................................................................................. 17
Freud............................................................................................................ 18
Heinrich....................................................................................................... 18
Norman....................................................................................................... 19
Rasmussen.................................................................................................. 19
Reason.......................................................................................................... 20
What Is Error..............................................................................................22
Error Taxonomies....................................................................................... 23
Incidents, Accidents, and Investigations..................................................... 24
Incidents and Accidents............................................................................ 24
Process Accidents....................................................................................... 25
Legal Definitions........................................................................................ 26
Investigations.............................................................................................. 27
From Antecedent to Error to Accident......................................................... 31
Assumptions............................................................................................... 31
General Model of Human Error Investigation...................................... 32
Antecedents................................................................................................34
Antecedents and Errors.............................................................................34

vii
viii Contents

Summary.......................................................................................................... 35
References........................................................................................................ 36

3. Analyzing the Data....................................................................................... 39

Introduction..................................................................................................... 39
Investigative Methodology............................................................................ 39
Ex Post Facto Designs................................................................................ 40
Imprecision................................................................................................. 41
An Illustration............................................................................................42
Analysis Objectives....................................................................................43
Assessing the Quality of the Data................................................................43
Internal Consistency..................................................................................43
Sequential Consistency............................................................................. 45
Data Value........................................................................................................ 46
Relevance..................................................................................................... 46
Quantity...................................................................................................... 47
Identifying the Errors..................................................................................... 47
The Sequence of Occurrences.................................................................. 47
The Error or Errors..................................................................................... 49
Assessing the Relationship of Antecedents to Errors............................... 50
Inferring a Relationship............................................................................ 50
Statistical Relationship.............................................................................. 50
Relating Antecedents to Errors................................................................ 51
Counterfactual Questions......................................................................... 52
Multiple Antecedents..................................................................................... 53
Cumulative Influence................................................................................ 53
Interacting Antecedents............................................................................54
Concluding the Search for Antecedents................................................. 56
Recommendations.......................................................................................... 57
Summary.......................................................................................................... 59
References........................................................................................................ 60

Section II Antecedents

4. Equipment.......................................................................................................65
Introduction.....................................................................................................65
Visual Information......................................................................................... 66
The Number of Displays........................................................................... 66
Organization and Layout.......................................................................... 67
Conspicuity................................................................................................. 68
Interpretability........................................................................................... 68
Trend Portrayal........................................................................................... 69
Aural Information........................................................................................... 69
Conspicuity................................................................................................. 70
Contents ix

Distractibility.............................................................................................. 70
Accuracy...................................................................................................... 71
Uniqueness.................................................................................................. 71
Relative Importance................................................................................... 72
Kinesthetic/Tactile Alerts.............................................................................. 74
Controls............................................................................................................ 74
Accessibility and Location........................................................................ 75
Direction of Movement and Function..................................................... 75
Mode Errors................................................................................................ 75
Shape............................................................................................................ 76
Placement.................................................................................................... 76
Standardization..........................................................................................77
Keyboard Controls..................................................................................... 78
Summary.......................................................................................................... 79
References........................................................................................................ 81

5. The Operator................................................................................................... 85
Introduction..................................................................................................... 85
Physiological Factors...................................................................................... 86
General Impairment.................................................................................. 86
Illness...................................................................................................... 86
Alcohol and Drugs of Abuse............................................................... 88
Specific Impairment...................................................................................90
Behavioral Antecedents................................................................................. 91
The Company’s Role.................................................................................. 92
Fatigue......................................................................................................... 92
Causes of Fatigue.................................................................................. 95
Investigating Fatigue............................................................................ 96
Preventing Fatigue................................................................................ 97
Stress............................................................................................................ 98
Person-Related Stress............................................................................ 99
System-Induced Stress........................................................................ 100
Case Study..................................................................................................... 100
Summary........................................................................................................ 102
References...................................................................................................... 105

6. The Company............................................................................................... 109

Introduction................................................................................................... 109
Organizations................................................................................................ 109
Hiring........................................................................................................ 110
Skills, Knowledge, and Predicted Performance............................. 110
The Number of Operators.................................................................. 111
Training................................................................................................ 112
Training Content................................................................................. 112
Instructional Media............................................................................ 113
x Contents

Costs versus Content.......................................................................... 114

Procedures................................................................................................. 114
General versus Specific....................................................................... 115
Oversight........................................................................................................ 115
New Operators......................................................................................... 116
Experienced Operators............................................................................ 117
“Good” Procedures.................................................................................. 118
Formal Oversight Systems........................................................................... 119
Line Operations Safety Audit................................................................ 119
Flight Operations Quality Assurance................................................... 119
Safety Management Systems.................................................................. 120
Company Errors............................................................................................ 121
Case Study..................................................................................................... 122
Summary........................................................................................................ 123
References...................................................................................................... 125

7. The Regulator............................................................................................... 127

Introduction................................................................................................... 127
What Regulators Do..................................................................................... 128
Regulator Activities................................................................................. 129
Enacting Rules..................................................................................... 130
Enforcing Rules................................................................................... 131
Case Study..................................................................................................... 132
Summary........................................................................................................ 135
References...................................................................................................... 136

8. Culture........................................................................................................... 137
Introduction................................................................................................... 137
National Culture........................................................................................... 139
National Cultural Antecedents and Operator Error................................ 142
Organizational Culture................................................................................ 144
Safety Culture........................................................................................... 144
Company Practices................................................................................... 145
High Reliability Companies................................................................... 147
Organizational Cultural Antecedents and Operator Error.................... 147
Summary........................................................................................................ 148
References...................................................................................................... 149

9. Operator Teams............................................................................................ 153

Introduction................................................................................................... 153
What Makes Effective Teams...................................................................... 154
Leadership................................................................................................. 154
Teamwork.................................................................................................. 155
Team Errors.................................................................................................... 156
Operator Team Errors................................................................................... 158
Contents xi

Failing to Notice or Respond to Another’s Errors............................... 158

Excessively Relying on Others............................................................... 158
Inappropriately Influencing the Actions or Decisions of Others...... 159
Failing to Delegate Team Duties and Responsibilities....................... 160
Operator Team: Antecedents to Error........................................................ 161
Equipment................................................................................................. 162
Operator.................................................................................................... 162
Company................................................................................................... 162
Number of Operators.............................................................................. 163
Team Structure......................................................................................... 163
Team Stability........................................................................................... 164
Leadership Quality.................................................................................. 165
Cultural Factors........................................................................................ 165
Case Study..................................................................................................... 166
Summary........................................................................................................ 168
References...................................................................................................... 169

Section III Sources of Data

10. Electronic Data............................................................................................. 175
Types of Recorders........................................................................................ 175
Audio/Video Recorders.......................................................................... 176
System-State Recorders........................................................................... 176
Other Electronic Data.............................................................................. 177
System Recorder Information..................................................................... 179
Audio Recorders....................................................................................... 179
The Equipment......................................................................................... 183
System-State Recorders........................................................................... 184
Integrating Information from Multiple Recorders.............................. 184
Assessing the Value of Recorded Data...................................................... 186
Audio Recorder Data............................................................................... 186
System-State Recorder Data.................................................................... 186
Summary........................................................................................................ 186
References...................................................................................................... 187

11. Interviews..................................................................................................... 189

Memory Errors.............................................................................................. 189
Interviewees and Their Concerns.............................................................. 191
Eyewitnesses............................................................................................. 191
System Operators..................................................................................... 192
Those Familiar with Operators and Critical System Elements......... 192
Information Sought...................................................................................... 192
Eyewitnesses............................................................................................. 193
Operators................................................................................................... 193
Those Familiar with Critical System Elements.................................... 194
xii Contents

The Cognitive Interview.............................................................................. 194

Rapport...................................................................................................... 195
Asking Questions..................................................................................... 196
False Responses........................................................................................ 197
Finding, Scheduling, and Selecting a Location for
the Interviews................................................................................................ 198
Eyewitnesses............................................................................................. 198
Operators................................................................................................... 198
Those Familiar with Critical System Elements.................................... 199
Administrative Concerns............................................................................ 200
The Interview Record.............................................................................. 200
Operator Team Members........................................................................ 201
Multiple Interviewers.............................................................................. 201
Information to Provide Interviewees.................................................... 202
Concluding the Interview....................................................................... 202
Interpreting Interview Data........................................................................ 202
Eyewitnesses............................................................................................. 202
Operators................................................................................................... 203
Those Familiar with Critical System Elements.................................... 203
Summary........................................................................................................ 203
References...................................................................................................... 206

12. Written Documentation............................................................................. 207

Introduction................................................................................................... 207
Documentation.............................................................................................. 207
Company-Maintained Documentation................................................. 208
Personnel Records............................................................................... 208
Training Records................................................................................. 208
Medical Records.................................................................................. 209
Documentation Not Maintained by the Company............................. 210
Information from Legal Proceedings............................................... 210
Family-Related Information.............................................................. 210
Driving History................................................................................... 210
Information Value......................................................................................... 211
Quantity.................................................................................................... 211
Collection Frequency and Regularity................................................... 212
Length of Time Since Collected............................................................. 212
Reliability.................................................................................................. 212
Validity...................................................................................................... 213
Changes in Written Documentation.......................................................... 213
Stable Characteristics............................................................................... 213
Organizational Factors............................................................................ 214
Summary........................................................................................................ 214
References...................................................................................................... 216
Contents xiii

Section IV Issues

13. Maintenance and Inspection..................................................................... 219

Introduction................................................................................................... 219
Maintenance Tasks....................................................................................... 220
Interpret and Diagnose........................................................................... 221
Act.............................................................................................................. 224
Evaluate..................................................................................................... 224
The Maintenance Environment.................................................................. 226
Lighting..................................................................................................... 226
Noise.......................................................................................................... 227
Environment............................................................................................. 227
Accessibility.............................................................................................. 227
Tools and Parts......................................................................................... 228
Time Pressure........................................................................................... 228
Case Study..................................................................................................... 229
Summary........................................................................................................ 232
References...................................................................................................... 235

14. Situation Awareness and Decision Making.......................................... 237

Introduction................................................................................................... 237
Situation Assessment and Situation Awareness...................................... 238
Situation Awareness: Operator Elements............................................. 240
Situation Awareness: Equipment Elements......................................... 242
Obtaining or Losing Situation Awareness................................................ 243
Obtaining Situation Awareness............................................................. 243
Losing Situation Awareness................................................................... 244
Decision Making........................................................................................... 245
Classical Decision Making...................................................................... 245
Naturalistic Decision Making................................................................ 246
Heuristics and Biases.............................................................................. 247
Errors Involving Naturalistic Decision Making.................................. 248
Decision-Making Quality versus Decision Quality............................ 250
Case Study..................................................................................................... 250
Information Available............................................................................. 251
Summary........................................................................................................254
References...................................................................................................... 255

15. Automation................................................................................................... 259

Introduction................................................................................................... 259
Automation.................................................................................................... 261
Automation Advantages and Disadvantages........................................... 262
Benefits....................................................................................................... 262
Shortcomings............................................................................................ 263
xiv Contents

Automation-Related Errors......................................................................... 269

Case Study..................................................................................................... 270
The Navigation System........................................................................... 270
The Accident............................................................................................. 271
Summary........................................................................................................ 272
References...................................................................................................... 273

16. Case Study..................................................................................................... 277

Introduction................................................................................................... 277
The Accident.................................................................................................. 277
Background.................................................................................................... 278
The Evidence................................................................................................. 280
The Pilots................................................................................................... 280
The Approach to San Francisco............................................................. 282
The Error........................................................................................................284
Antecedents to Error.................................................................................... 285
Operator Antecedents: Experience........................................................ 286
Operator Antecedents: Fatigue.............................................................. 287
Equipment Antecedents: Airplane System Complexity
and Automation Opacity........................................................................ 287
Equipment Antecedents: Equipment Information.............................. 289
Company Antecedents: Automation Policy......................................... 289
Antecedents and Errors............................................................................... 291
Relationships between Antecedents and Errors................................. 291
Terminating the Search for Antecedents.............................................. 291
Recommendations........................................................................................ 292
Summary........................................................................................................ 293
References...................................................................................................... 294

17. Final Thoughts............................................................................................. 297

Investigative Proficiency.............................................................................. 298
Criteria............................................................................................................ 298
Models of Error, Investigations, and Research......................................... 299
Research and Investigations...................................................................300
Quick Solutions........................................................................................ 301
Conclusions.................................................................................................... 301
References...................................................................................................... 301
Index...................................................................................................................... 303
Foreword to Second Edition

Many accident investigations make the same mistake in defining causes.

They identify the widget that broke or malfunctioned, then locate the
person most closely connected with the technical failure: the engineer
who miscalculated an analysis, the operator who missed signals or
pulled the wrong switches, the supervisor who failed to listen, or the
manager who made bad decisions. When causal chains are limited to
technical flaws and individual failures, the ensuing responses aimed at
preventing a similar event in the future are equally limited: they aim to
fix the technical problem and replace or retrain the individual respon-
sible. Such corrections lead to a misguided and potentially disastrous
belief that the underlying problem has been solved. (Columbia Accident
Investigation Board, 2003, p. 97)

I’ll never forget the day my phone rang early on a Sunday morning in 2006.
The voice on the other end of the line informed me there had been an air-
line crash in Lexington, Kentucky. The airplane was still on fire and mul-
tiple fatalities were expected. With that, I started packing my bags to head
to Kentucky.
Before even leaving my house, the images on TV pretty much told me what
had happened. The wreckage was positioned a few thousand feet directly off
the end of a runway that would have been too short for an airplane of that
size to successfully takeoff. A broken fence at the end of the runway and tire
marks through the grass to the initial impact point provided further clues.
So, before even leaving my house, I had surmised the pilots made an error of
attempting to depart from the wrong runway.
Error identified, case closed. Right?
Well, actually not. A good friend, Captain Daniel Maurino, stated “the
discovery of human error should be considered as the starting point of the
investigation, and not the ending point that has punctuated so many previ-
ous investigations” (Maurino, 1997). His words of wisdom are framed in my
office to serve as a constant reminder of the necessity to look behind the
obvious human error. It is one thing to say someone committed an error, but
it is quite another to try to identify the underlying factors that influenced
that error. And why do we care? Finding who or what is at “fault” should
not be simply an exercise in attributing error, but rather, should be for the
purpose of identifying the factors that influenced the error so those condi-
tions can be corrected to prevent future errors. If we simply say “human
error,” “pilot error,” or “operator error,” and stop with that, we miss valuable
learning opportunities. The Institute of Medicine noted in a seminal report
on medical error that “blaming the individual does not change these factors
and the same error is likely to recur” (Institute of Medicine, 2000, p. 49).

xv
xvi Foreword to Second Edition

In the case of the Lexington, Kentucky crash, the error was identified
within hours, if not minutes, after it occurred. But, identifying the human
error doesn’t mean the investigation is completed; instead, it should be, as
Daniel Maurino stated, the starting point of the investigation.
Once the human error was identified, the prevailing question should (and
did) become “Why was the error committed?” Were the pilots fatigued? Did
the fact that the airport was undergoing construction of runways and taxi-
ways somehow confuse the pilots during taxi-out? How did the disparity
between taxiway signs and what was depicted on the pilots’ airport dia-
gram charts affect their performance? Did organizational factors such as
poor training or lack of company standardization somehow contribute to
the error? What role did understaffing in the control tower play? Did the
crew’s casual attitude enable their error? Why did two other flights success-
fully navigate the airport construction and taxi to the correct runway in the
moments before the crash, but this crew did not? Only after questions such
as these are answered can the human error be understood and the underly-
ing conditions corrected.
Since that accident in 2006, I’ve been involved in the deliberation of some
150 or so transportation accidents. From that experience, I have developed
the belief that most, if not all, accidents or incidents have roots in human
error. In some cases, it is a readily identifiable error of a frontline opera-
tor, such as a pilot, ship’s master, medical technician, air traffic controller, or
control room operator. In other cases, the error(s) may not be obvious at all.
It may be deeply embedded within the system, perhaps far, far away from
the scene of the accident, such as decisions and actions/inactions made by
organizations or regulators. As explained in this book, there are proximate
errors—those that are closest to the accident in terms of timing or location,
and there are underlying conditions that are factors in the accident causa-
tion, but perhaps not readily apparent. Reason (1990, 1997) refers to these as
active failures, and latent conditions, respectively.
Contemporary thinking views error as a “symptom of deeper trouble”
(Dekker, 2002, p. 61) within the system. Maurino said human error should
be “considered like fever: an indication of illness rather than its cause. It is a
marker announcing problems in the architecture of the system” (Maurino,
1997).
In the early 1990s, then National Transportation Safety Board (NTSB)
board member John Lauber was one of the first to focus on how organiza-
tional factors can influence transportation safety (Meshkati, 1997). Lauber
argued that the cause of a commuter airliner in-flight breakup due to faulty
maintenance should be “the failure of Continental Express management to
establish a corporate culture which encouraged and enforced adherence
to approved maintenance and quality assurance procedures” (NTSB, 1992,
p. 54). Of the five NTSB board members, Lauber was alone in his belief. The
conventional thinking at the time seemed to be to identify the proximate
Foreword to Second Edition xvii

error that sparked the accident and call that the “cause” of the mishap. But,
as discussed throughout this book, human error does not occur in a vacuum.
It must therefore be examined in the context in which the error occurred.
In other words, if an error occurs in the workplace, the workplace must be
examined to look for conditions that could provoke error. What were the
physical conditions at the workplace? Was lighting adequate to perform the
task? Were the procedures and training adequate? Did the organizational
norms and expectations prioritize safety over competing goals? Was the
operational layout of the workplace conducive for error?
Organizational factors have been implicated in accidents and incidents in
many socio-technical industries. For example, the U.S. Chemical Safety and
Hazard Investigation Board (Chemical Safety Board [CSB]) determined that
a 2005 oil refinery explosion that claimed 15 lives and injured 180 people had
numerous organizational-related factors, such as the company’s cost cutting
and overreliance on misleading safety metrics (CSB, 2007). The International
Atomic Energy Agency (IAEA) stated that the Chernobyl nuclear power
plant meltdown “flowed from a deficient safety culture, not only at the
Chernobyl plant, but throughout the Soviet design, operating, and regula-
tory organizations for nuclear power” (IAEA, 1992, pp. 23–24). The National
Transportation Safety Board (2010) found organizational issues to be a causal
factor in the 2009 multi-fatality subway accident in Washington, DC.
In 2015, I was involved in the final deliberation of an accident involving
SpaceShipTwo, a commercial space vehicle that suffered an in-flight breakup
during a test flight. From the onboard video recorder, it was evident that the
copilot prematurely moved a lever which led to an uncommanded move-
ment of the vehicle’s tail feather—a device similar to a conventional aircraft’s
horizontal and vertical stabilizer. The tail feather is actuated by a cockpit
lever to pivot it upward 60° relative to the longitudinal axis of the aircraft;
its purpose is to stabilize the aircraft during the reentry phase of flight.
However, if the feather is deployed at the wrong time, as in this case, the
resulting aerodynamic loads on the aircraft will lead to catastrophic in-flight
breakup. The obvious “cause” of the accident was that the copilot committed
an error of unlocking the feather at the wrong time which led to the uncom-
manded actuation of the feather. But, this finding alone would serve no use-
ful purpose for preventing similar errors in the future. After all, the copilot
was killed, so surely he would not commit this error again.
By digging deeper, the investigation found that influencing the ­copilot’s
error was the high workload he was experiencing during this phase of
flight, along with time pressure to complete critical tasks from memory—
all while experiencing vibration and g-loads that he had not experienced
recently. On the broader perspective, the spaceship designer/manufac-
turer, Scaled Composites, did not consider that this single error could lead
to an unintended feather activation. Although the copilot had practiced
for this flight several times in the simulator, this premature movement
xviii Foreword to Second Edition

of the feather unlock lever occurred on the fourth powered flight of the
SpaceShipTwo, indicating to me that the likelihood of this error was high.
“By not considering human error as a potential cause of uncommanded
feather extension of the SpaceShipTwo, Scaled Composites missed oppor-
tunities to identify the design and/or operational requirements that could
have mitigated the consequences of human error during a high workload
phase of flight” (NTSB, 2015, p. 67). Because of the underlying design
implications, the National Transportation Safety Board issued a safety rec-
ommendation to the Federal Aviation Administration (FAA) to ensure that
commercial space flight entities identify and address “single flight crew
tasks that, if performed incorrectly or at the wrong time, could result in
a catastrophic hazard” (NTSB, 2015, p. 70). In addition, the manufacturer
added a safety interlock to ensure that this lever could not be activated
during this critical flight regime.
Not only can organizations create error provoking conditions, but regula-
tors can do so as well. Examples include failing to provide adequate oversight
and enforcement, or not developing adequate procedures. In 2009, a Pacific
Gas & Electric Company (PG&E) 30-inch diameter natural gas transmission
pipeline ruptured and exploded. The conflagration claimed eight lives in
San Bruno, California, destroyed 38 homes and damaged 70. The investiga-
tion determined that oversight and enforcement by both the state and federal
regulators was ineffective, which “permitted PG&E’s organizational failures
to continue over many years” (NTSB, 2011, p. 126).
So, as you can see, human behavior, including errors, can be influenced by
many factors. Therefore, investigation of human error should not be a ran-
dom hit or miss process. It should be conducted in an organized, methodical
process, with a clear purpose in mind. Dr. Barry Strauch has been on the
frontlines of investigating human error for nearly 35 years and he has pro-
vided human factors expertise to well over a hundred aviation and maritime
accidents. Between the covers of this book, he lays out in clear terms the fac-
tors that enable human error, including individual factors such as fatigue,
stress, and medical factors. He also examines in detail organizational and
regulatory precursors to error. Each chapter provides a bulleted checklist to
facilitate identifying relevant factors. This second edition provides an update
to what I found to be an excellent reference—one that I often referred to in
my decade of serving on an accident investigation board, as indicated by
scores of dog-eared pages filled with underlining and highlighting. I encour-
age anyone involved with investigating any type of error—whether that error
occurred in the hospital, on the hangar floor, in a nuclear control room, or
on the flight deck of an airliner—to use this text as resource to investigating
human error. Using this book as a guide—I assure you—will not be an error.

Robert L. Sumwalt
Washington, DC
Foreword to Second Edition xix

References
Chemical Safety Board. 2007. Investigation report: Refinery explosion and fire. BP,
Texas City, TX. CSB Report No. 2005-04-I-TX. Washington, DC: Chemical Safety
Board.
Columbia Accident Investigation Board. 2003. Columbia accident investigation board
report (Vol. 1). Washington, DC: Columbia Accident Investigation Board.
Dekker, S. 2002. The field guide to human error investigations. Aldershot, England:
Ashgate Publishing International.
Institute of Medicine. 2000. To err is human: Building a safer health system. Washington,
DC: National Academy Press.
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Maurino, D. E. 1997. Aviation human factors and the safety investigation process.
Paper presented at ISASI 1997 International Air Safety Conference, Anchorage, AK.
Meshkati, N. 1997. Human performance, organizational factors and safety culture.
National Transportation Safety Board Symposium on Corporate Culture in
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National Transportation Safety Board. 1992. Aircraft accident report: Britt Airways,
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Washington, DC: National Transportation Safety Board.
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Foreword to First Edition

Like the rest of the modern world, I owe an enormous debt to the skills
of professional accident investigators. As a traveler and a consumer, I am
extremely grateful for what they have done to make complex technologies
significantly safer; but as an academic, I have also been especially dependent
on their published findings. Although, mercifully, I have had very little first-
hand experience of the real thing, this has not prevented me from writing,
lecturing, and theorizing about the human contribution to the breakdown of
complex systems for the past 30 years or so. There are perhaps two reasons
why I have so far been able to pull this off. The first is that the ivory tower
provided the time and resources to look for recurrent patterns in a large
number of adverse events over a wide range of hazardous technologies, a
luxury that few “real-world” people could enjoy. The second has been the
high quality of most major accident reports. If such accounts had later been
shown to lack accuracy, insight, analytical depth, or practical value, then
my reliance upon them would have been foolish or worse. But while many
have challenged the theories, very few have questioned the credibility of the
sources.
So, you might ask, if accident investigators are doing so well, why do they
need this book? The most obvious answer is that human, organizational, and
systemic factors, rather than technical or operational issues, now dominate
the risks to most hazardous industries—yet the large majority of accident
investigators are technical and operational specialists. Erik Hollnagel (1993)
carried out a survey of the human factors literature over three decades to
track the increasing prominence of the “human error” problem. In the 1960s,
erroneous actions of one kind or another were estimated as contributing
around 20% of the causal contributions to major accidents. By the 1990s, how-
ever, this figure had increased fourfold. One obvious explanation is that the
reliability of mechanical and electronic components has increased markedly
over this period, while complex systems are still being managed, controlled,
and maintained by Mark I human beings.
In addition, this period has seen some subtle changes in the way we per-
ceive the “human error” problem and its contribution to accidents. For the
most part, “human error” is no longer viewed as a single portmanteau cate-
gory, a default bin into which otherwise unexplained factors can be dumped.
We now recognize that erroneous actions come in a variety of forms and
have different origins, both in regard to the underlying psychological mech-
anisms and their external shaping factors. It is also appreciated that front-
line operators do not possess a monopoly on error. Slips, lapses, mistakes,
and violations can occur at all levels of the system. We are now able to view
errors as consequences rather than sole causes, and see frontline operators

xxi
xxii Foreword to First Edition

more as the inheritors rather than the instigators of accidents in complex

systems.
System complexity derives in large part from the existence of diverse and
redundant layers of defences, barriers, and safeguards that are designed to
prevent operational hazards from coming into damaging contact with peo-
ple, assets, and the environment. The nuclear industry calls them “defenses-
in-depth.” Such characteristics make it highly unlikely that accidents in
complex systems arise from any single factor, be it human, technical, or envi-
ronmental. The apparently diabolical conjunction of several different factors
is usually needed to breach all of these defenses-in-depth at the same time.
This makes such events less frequent, but the causes more complex. Some
of the latent contributions have often lain dormant in the system for many
years prior to the accident. Given the increasing recognition that contribut-
ing factors can have both a wide scope and a long history, it is almost inevi-
table that investigators will net larger numbers of human and organizational
shortcomings.
Another associated change—at least within the human factors and inves-
tigative communities—has been a shift away from the “person model” of
human error, in which the search for causes and their countermeasures is
focused almost exclusively upon the psychology of individuals. Instead, there
has been an increasing willingness to take a systems view of accident causa-
tion in which the important question is not “Who blundered?” but “How and
why did the defenses fail?” Unfortunately, the person model is still deeply
embedded in the human psyche, and is especially pernicious in its moral (or
legal) form. This is the widespread belief that responsible and highly trained
professionals (pilots, surgeons, ship’s officers, control room operators, and
the like) should not make errors. However, when such erroneous actions do
occur, it is assumed that they are sufficient to cause bad accidents. The reality,
of course, is quite different. Highly trained, responsible professionals make
frequent errors, but most are inconsequential, or else they are detected and
recovered (see, e.g., Amalberti and Wioland, 1997). Moreover, these errors are
only occasionally necessary to add the final touches to an accident-in-waiting,
a potential scenario that may have been lurking within a complex system for
a long time.
The achievements of accident investigators are all the more remarkable
when one considers the snares, traps, and pitfalls that lie in their path. Aside
from the emotional shock of arriving at often inaccessible and hostile loca-
tions to confront the horrors of an accident site, investigators are required to
track backward—sometimes for many years—in order to create a coherent,
accurate, and evidence-based account of how and why the disaster occurred,
and to make recommendations to prevent the recurrence of other tragedies.
The first and most obvious problem is that the principal witnesses to the acci-
dent are often dead or incapacitated. But this, as most investigators would
acknowledge, goes with the territory. Other difficulties are less apparent and
have to do with unconscious cognitive biases that influence the way people
Foreword to First Edition xxiii

arrive at judgments about blame and responsibility and cause and effect.
While human factors specialists have focused mainly upon the error tenden-
cies of the operators of complex systems, there has also been considerable
interest in how people trying to make sense of past events can go astray. Let
me briefly review some of these investigative error types. They fall into two
related groups: those that can bias attributions of blame and responsibility
and those that can distort perceptions of cause and effect.
Here are some of the reasons why the urge to blame individuals is so
strong. When looking for an explanation of an occurrence, we are biased to
find it among human actions that are close in time and place to the event,
particularly if one or more of them are considered discrepant. This leads to
what has been termed the counterfactual fallacy (Miller and Turnbull, 1990)
where we confuse what might have been with what ought to have been, par-
ticularly in the case of bad outcomes. The fallacy goes as follows: Had things
been otherwise (i.e., had this act not happened), there would have been no
adverse result; therefore, the person who committed the act is responsible
for the outcome.
Another factor that leads to blaming is the fundamental attribution error
(Fiske and Taylor, 1984). This is the universal human tendency to resort to
dispositional rather than to situational influences when explaining people’s
actions, particularly if they are regarded as unwise or unsafe. We say that the
person was stupid or careless; but, if the individual in question were asked,
he or she is most likely to point to the local constraints. The truth usually lies
somewhere in between.
The just world hypothesis (Lerner, 1970)—the view that bad things hap-
pen to bad people, and conversely—comes into play when there is an espe-
cially unhappy outcome. Such a belief is common among children, but it can
often last into adulthood. A close variant is the representativeness heuristic
(Tversky and Kahneman, 1974) or the tendency to presume a symmetrical
relationship between cause and effect—thus bad consequences must be
caused by horrendous blunders, while particularly good events are seen as
miracles.
Yet another reason why people are so quick to assign blame is the illu-
sion of freewill (Lefcourt, 1973). People, particularly in western cultures, place
great value in the belief that they are the controllers of their own fate. They
can even become mentally ill when deprived of this sense of personal free-
dom. Feeling themselves to be capable of choice naturally leads them to
assume that other people are the same. They are also seen as free agents,
able to choose between right and wrong, and between correct and erroneous
actions. But our actions are often more constrained by circumstances than
we are willing to admit or understand.
All accident investigators are faced with the task of digitizing an essentially
analog occurrence; in other words, they have to chop up continuous and
interacting sequences of prior events into discrete words, paragraphs, con-
clusions, and recommendations. If one regards each sequence as a piece of
xxiv Foreword to First Edition

string (though it is a poor analogy), then it is the investigator’s task to tie

knots at those points marking what appear to be significant stages in the
development of the accident. Such partitioning is essential for simplifying
the causal complexity, but it also distorts the nature of the reality (Woods,
1993). If this parsing of events correctly identifies proper areas for remedia-
tion, then the problem is a small one; but it is important for those who rely
on accident reports to recognize that they are—even the best of them—only
a highly selected version of the actuality, and not the whole truth. It is also
a very subjective exercise. Over the years, I have given students the task of
translating these accident narratives into event trees. Starting with the acci-
dent itself, they were required to track back in time, asking themselves at each
stage what factors were necessary to bring about the subsequent events—or,
to put it another way, which elements, if removed, would have thwarted the
accident sequence. Even simple narratives produced a wide variety of event
trees, with different nodes and different factors represented at each node.
While some versions were simply inaccurate, most were perfectly acceptable
accounts. The moral was clear: the causal features of an accident are to the
analyst what a Rorschach test (inkblot test) is to the psychologist—some-
thing that is open to many interpretations. The test of a good accident report
is not so much its fidelity to the often-irrecoverable reality, but the extent to
which it directs those who regulate, manage, and operate hazardous tech-
nologies toward appropriate and workable countermeasures.
A further problem in determining cause and effect arises from the human
tendency to confuse the present reality with that facing those who were
directly involved in the accident sequence. A well-studied manifestation
of this is hindsight bias or the knew-it-all-along effect (Fischhoff, 1975; Woods
et al., 1994). Retrospective observers, who know the outcome, tend to exag-
gerate what the people on the spot should have appreciated. Those looking
back on an event see all the causal sequences homing in on that point in time
at which the accident occurred; but those involved in the prior events, armed
only with limited foresight, see no such convergence. With hindsight, we
can easily spot the indications and warning signs that should have alerted
those involved to the imminent danger. But most “warning” signs are only
effective if you know in advance what kind of accident you are going to have.
Sydney Decker (2001) has added two further phenomena to this catalog of
investigative pitfalls: he termed them micro-matching and cherry-picking. Both
arise, he argues, from the investigator’s tendency to treat actions in isolation.
He calls this “the disembodiment of human factors data.” Micro-matching is a
form of hindsight bias in which investigators evaluate discrete performance
fragments against standards that seem applicable from their after-the-fact
perspective. It often involves comparing human actions against written
guidance or data that were accessible at the time and should have indicated
the true situation. As Decker puts it: “Knowledge of the ‘critical’ data comes
only with the omniscience of hindsight, but if data can be shown to have
been physically available, it is assumed that it should have been picked up by
Foreword to First Edition xxv

the practitioners in the situation.” The problem, he asserts, is that such judg-
ments do not explain why this did not happen at the time. Cherry-picking,
another variant of hindsight bias, involves identifying patterns of isolated
behavioral fragments on the basis of post-event knowledge. This grouping
is not a feature of the reality, but an artifact introduced by the investigator.
Such tendencies, he maintains, derive from the investigator’s excessive reli-
ance upon inadequate folk models of behavior, and upon human reactions
to failure. Fortunately, he outlines a possible remedy “in the form of steps
investigators can take to reconstruct the unfolding mindset of the people
they are investigating, in parallel and tight connection with how the world
was evolving around these people at the time.”
Clearly, accident investigators need help in making sense of human factors
data. But I am not sure that Olympian pronouncements (or even Sinaian tab-
lets) are the way to provide it, nor am I convinced that investigators can ever
“reconstruct the unfolding mindset of the people they are investigating”—I
can’t even construct my present mindset with any confidence. This book, on
the other hand, delivers the goods in a way that is both useful and meaning-
ful to hard-pressed accident investigators with limited resources. It is well
written, well researched, extremely well informed, and offers its guidance
in a down-to-earth, practical, and modular form (i.e., it can be read via the
contents page and index rather than from cover to cover). It is just the thing,
in fact, to assist real people doing a vital job. And, as far as I know, there is
nothing else like it in the bookshops.

James Reason

References
Amalberti, R. and L. Wioland. 1997. Human error in aviation. In H. M. Soekkha (Ed.),
Aviation safety, pp. 91–108. Utrecht, The Netherlands: VSP.
Decker, S. W. A. 2001. The disembodiment of data in the analysis of human factors
accidents. Human Factors and Aerospace Safety, 1: 39–58.
Fischhoff, B. 1975. Hindsight is not foresight: The effect of outcome knowledge
on judgement under uncertainty. Journal of Experimental Psychology: Human
Perception and Performance, 1: 288–299.
Fiske, S. T. and S. E. Taylor. 1984. Social cognition. Reading, MA: Addison-Wesley.
Hollnagel, E. 1993. Human reliability analysis: Context and control. London: Academic
Press.
Lefcourt, H. M. 1973. The function of illusions of control and freedom. American
Psychologist, May, 417–425.
Lerner, M. J. 1970. The desire for justice and the reaction to victims. In J. McCauley
and I. Berkowitz (Eds.), Altruism and helping behavior, pp. 205–229. NY: Academic
Press.
xxvi Foreword to First Edition

Miller, M. W. and W. Turnbull. 1990. The counterfactual fallacy: Confusing what

might have been with what ought to have been. Social Justice Research, 4: 1–9.
Tversky, A. and D. Kahneman. 1974. Judgment under uncertainty: Heuristics and
biases. Science, 185: 1124–1131.
Woods, D. D. 1993. Process tracing methods for the study of cognition outside of
the experimental laboratory. In G. A. Klein, J. Orasunu, R. Calderwood, and
C. E. Zsambok (Eds.), Decision making in action: Models and methods, pp. 228–251.
Norwood, NJ: Ablex.
Woods, D. D., L. J. Johannesen, R. I. Cook, and N. B. Sarter. 1994. Behind human error:
Cognitive systems, computers and hindsight. Dayton, OH: CSERIAC.
Preface to Second Edition

I have seen many changes in the understanding of human error as well as

in the role that it plays in accident causation in the 15 years since this book
was first published. In that time, considerable research has been conducted
in such areas as automation, team performance, safety management, and
fatigue, research that has given investigators additional knowledge with
which to assess the causes of human error. In this interval, we have also
witnessed a worldwide decline in major aircraft accidents. Unfortunately,
some of the accidents that have occurred since then appear to have been
influenced by the same antecedents to error that we have seen all too fre-
quently over the years. For example, the accident used in the case study in
Chapter 16, while more current and with more complex errors than was true
of the case study in the first edition, illustrates automation-related errors that
are almost identical to those seen in previous accidents, including one com-
mitted almost 30 years earlier. Because people and the systems they operate
do not always learn from their mistakes, the need for thorough and system-
atic human factors investigations of error becomes that much more critical.
Hopefully, the lessons to be learned from these investigations can be used to
avoid further accidents.
Not only have operators continued to make errors that have led to acci-
dents, but mishaps in which the antecedents were well known but ignored
have occurred in other systems as well. For example, the case of Bernard
Madoff, whose Ponzi scheme cost many investors their life savings, illus-
trates how ineffective oversight can exacerbate system errors. The U.S. regu-
lator of financial securities had been informed of the Madoff Ponzi scheme
well before the scheme was exposed, yet nothing was done to stop him,
despite its own (flawed) investigation and the presence of publicly available
information that could have pointed out the fraud. The regulator did not
cause the scheme, but by failing to properly oversee the financial system
in which it operated, it contributed to losses of millions of investor dollars
beyond what would have been the case had it acted effectively when it ini-
tially learned of the scheme.
In the years since the first edition, we have also witnessed the world’s
third major civilian nuclear reactor accident, the March 2011 meltdown in
the Fukushima Daiichi nuclear generating plant in Japan. A reactor core
melted after coolant ceased flowing to it, following flooding of the backup
diesel generators, a result of a devastating tsunami. Because the plant was
located in a seismic zone, near the ocean, it was potentially prone to tsu-
namis. Regulators therefore required protection against them. In addition
to building a seawall, designers had installed backup generators to enable
coolant to be pumped to the core in the event that primary power was lost.

xxvii
xxviii Preface to Second Edition

However, although backup generators were required and installed, design-

ers and regulators failed to consider the possibility of a tsunami of sufficient
magnitude that would exceed the seawall limits and flood the backup gen-
erators, which had been placed at ground level behind the seawall. In this
manner, designers, regulators, operators, and all who play integral roles in
complex systems, have continued to create antecedents to errors that appear,
in hindsight, to have been preventable.
While this book does not attempt to provide foresight to those design-
ing or operating complex systems, I do hope that it will provide knowledge
needed to effectively investigate the results of their errors to identify their
antecedents. Because of the findings of both accident investigations and
of the human factors research conducted in the interim, we have a better
understanding of error causation than we did 15 years ago. We know more,
for example, than we did then about automation’s effects on operators, on
how fatigue can adversely affect cognitive performance, and how organi-
zations can contribute to operator errors and the research cited in this text
reflects these advances.
My experience as an investigator, with now over 30 years of conduct-
ing error investigations in major modes of transportation, has reinforced
my belief that error investigators need to be aware of basic human factors
research findings. The ability to identify necessary data, along with inter-
viewing and analytical skills, are all necessary. But without an understand-
ing of human error even the most skilled investigators will have difficulty
explicating the error causation in the accidents they investigate.
In the first edition, I suggested that accident investigation is a special call-
ing and my experience since then has only reinforced that view. To be able to
understand and identify errors in a way that is constructive, and that can be
used to prevent accidents, is indeed a privilege. I hope that you will find this
text helpful and contributing to your own endeavors. Should you investigate
an accident, I hope that you will make a positive contribution to safety by
helping to reduce its likelihood in the future.
Finally, this book is dedicated to the memory of Howard B. Brandon, Jr.,
whose father has been a colleague, mentor, and friend. May Howard rest in
peace.

Barry Strauch
Annandale, Virginia
Another random document with
no related content on Scribd:
almost necessary to pinch myself to see if I was really awake. It
seemed more like a fable.
On June 20th at 2 a.m. the “Heimdal” left the Bay with flying-men,
mechanics, and photographer on board. They were off to Brandy Bay
to fetch the machine. At eight next evening they were back with the
apparatus in good order. We were dining when they arrived, but the
hum of the motor brought us all to our feet. There she came gliding
elegantly along and landed immediately afterwards. Now we got a
holiday which we all keenly appreciated. It reminded me of my happy
days when I could lie in idleness in the country and get fat! Hundreds
of telegrams streamed in daily from all corners of the world. The King
and Queen were first to send a greeting: “The Queen and I wish you
and your companions welcome back. I thank you for your enterprise
and that you have again brought honor to Norway. Haakon R.” The
Crown Prince’s followed immediately after. Then came the Storthing,
the Government, the Universities, all the towns, a number of districts
and clubs and all the foreign Legations. Telegrams from abroad also
poured in with congratulations—one from the English King, the
German President, the Geographic and Scientific Associations, among
others. Those were hard days for the telegraphers here in the north,
but they were unusually smart. The telegraph service on board the
“Fram” and the “Heimdal” gave us invaluable assistance. In addition to
this the King’s Bay Coal Company’s telegrapher, Herr Hagenis, worked
at high pressure all the time.
On June 23rd “Hobby” left us to return to her home—Tromsö. It
was like losing an old friend, for we had been so glad to have with us
all these clever, splendid people, who went with her; Ramm and Berge
accompanied them.
St. Hans’ Eve was celebrated with due ceremony,—bonfire, song
and dance. The Coal Company’s chartered boat “Albr. W. Selmer,”
which came into the station on the 21st of June, was finished by the
25th with loading coal and took on board (the same afternoon) N 25
and the Navy’s two Hansa-Brandenburgers. They were shipped as
they lay on the water—N 25 forward and the two others aft. The “Albr.
W. Selmer” was suddenly turned into something which looked like a
cross between fish and fowl. The planes were stretched out at both
sides, and must have offered a most unusual sight to any ship meeting
her. “Selmer” was an old boat, but quite able to take the whole
expedition south. Furthermore, she had sufficient room to carry the
machines quite easily and could house all the members. Captain
Aasgard, her captain, and his officers made room for us with
customary Norwegian hospitality and kindness and we of the
expedition had the whole of the ship’s after-part given over to us. Thus
we had the officers’ quarters and saloon. It was hard to say good-by to
Knutsen and King’s Bay. We shall always hold as one of our dearest
memories the wonderful hospitality and kindly care which was shown
to us there on our return. At eleven o’clock the “Selmer” left King’s Bay
in glorious weather. The midnight sun stood high in the heavens and
the hills around were brightly illumined. From the “Heimdal” we heard
the sounds of them playing “Ja vi elker” and from the Station’s height
cheers broke out. The flags were dipped—one last farewell and the
Station disappears—our dear home—behind us. We were ten
passengers: Captain Hagerup, Lieuts. Riiser-Larsen, Dietrichson,
Horgen, Lutzow-Holm, Omdal, Zapffe, Feucht, Ellsworth and myself. It
was an unforgettable holiday—and festal journey. The intention was
that we should sail down outside the Islands all the way, anchoring at
Lang-Grunnen, from whence we should enter Horten. This, however,
was altered as time passed. We met a heavy swell coming from the
east, making it dangerous for our machines. We must therefore “hug
the coast” as quickly as possible, and at 11 a.m., June 29th, we passed
Fugleö. Telegrams continued to come in such numbers that the ship’s
second mate, who was also radio-telegrapher, was overworked. Near
Tromsö we were overhauled by the S.S. “Richard With,” belonging to
the Vesteraalske Steamship Company. As it passed, it hoisted its flags
and broke out into loud cheers, as all on board waved and shouted.
This was the first greeting we had had of this kind. Unexpectedly as it
came it absolutely overwhelmed us. It was a delightful greeting and will
never be forgotten. Now we had an idea what awaited us elsewhere
and as we saw the tremendous preparations in Tromsö Sound we
were prepared. Out shot two large flag-bedecked ships full of festal-
clad jubilant people. A little further forward we saw our old friend
“Hobby” so gayly decorated and so laden with people that she took our
breath away. Speeches were made, songs were sung and people
cheered. The passage through Tromsö Sound was triumphant—a
proof of the warm-hearted hospitality characteristic of the people. The
wonderful summer weather continued all the time and our journey
along the coast was like a trip through Dreamland. Our beautiful flag
was to be seen everywhere and greeted us with the same glowing
warmth. Fir trees and birches were dressed in their most lovely green
reminding us of Fairyland as we glided past. Here and there lay
solitary little fishing-boats and I felt many times a lump in my throat
when their sunburnt men stood up, raised their hats and sent us their
“Welcome Home.” It was a calm but deep welcome which, in contrast
to other more demonstrative greetings, filled us with emotion.
Outside Kristiansand we received our first welcome from the air. It
was the Fleet and the Army greeting us. Four Hansa-Brandenburgers
circled round us once and then disappeared.
On the afternoon of July 4th we passed Færder and entered Oslo-
Fjord and were met with jubilant crowds by air and by sea. At Fuglehuk
we encountered one of the most affecting scenes which we had lived
through all the time, the meeting between the flying-men and their
wives. The companion ladder was lowered, all heads were bared, and
the two women, who had borne the hardest part of the expedition,
climbed on board. If I only had command of all the world’s flags I would
dip them in honor, if I only had all the world’s guns I would fire them all,
to give these brave women a reception worthy of an Empress, for as
such I regarded them.
At eleven o’clock at night we sailed into Horten’s Quay. Any
attempt to describe this would be in vain. It was like the Arabian
Nights. I was happy to go ashore at Horten, for in the past I had
harvested so much good there that I was deeply grateful to this place.
Not one of my expeditions had ever set out without the Norwegian
Navy playing a great part; this last one being indebted in an
overwhelming degree. It was through the Norwegian Navy’s Air
Service that this last trip was really made possible. Thanks to their
liberal granting of necessary permission, thanks to their giving us
clever men; thanks to them again it was possible to set off on our
enterprise.
Thus came the day—the great, the unforgettable day—the 5th of
July, 1925. Summer favored us in its fullest glory. Who can describe
the feelings which rose within us as we of the N 25 flew in, over the
flag-bedecked capital, where thousands upon thousands of people
stood rejoicing? Who can describe the sights that met us as we
descended to the water surrounded by thousands of boats? The
reception on the quay? The triumphant procession through the
streets? The reception at the Castle? And then, like a shining crown
set upon the whole, their Majesties’ dinner at the Castle. All belongs to
remembrance—the undying memory of the best in a lifetime.
 Part II
THE AMUNDSEN-ELLSWORTH POLAR FLIGHT

By Lincoln Ellsworth
 THE AMUNDSEN-ELLSWORTH
POLAR FLIGHT
So long as the human ear can hark back to the breaking of
waves over deep seas; so long as the human eye can follow the
gleam of the Northern Lights over the silent snow fields; then so
long, no doubt, will the lure of the unknown draw restless souls into
those great Arctic wastes.
I sit here about to set down a brief record of our late Polar
experience, and I stop to try to recall when it was that my
imagination was first captured by the lure of the Arctic. I must have
been very young, because I cannot now recall when first it was.
Doubtless somewhere in my ancestry there was a restless wanderer
with an unappeasable desire to attain the furthest north. And, not
attaining it, he passed it on with other sins and virtues to torment his
descendants.
The large blank spaces surrounding the North Pole have been a
challenge to the daring since charts first were made. For nearly four
generations that mysterious plain has been the ultimate quest of
numberless adventurers.
Before this adventure of ours explorers had depended upon
ships and dogs. Andrée and Wellmann planned to reach the Pole
with balloons, but theirs were hardly more than plans. Andrée met
with disaster soon after leaving Spitzbergen. Wellmann’s expedition
never left the ground.
What days they were—those ship and dog days! What small
returns came to those men for their vast spending of energy and toil
and gold! I am filled with admiration for the courage and the
hardihood of the men who cut adrift from civilization and set out with
dogs or on foot over the tractless ice fields of the Far North. All honor
to them! Yet now what utter neglect it seems of the resources of
modern science!
No doubt the men who have been through it best realize what a
hopeless, heart-breaking quest it was. Peary’s land base at Camp
Columbia was only 413 miles from the Pole; yet it took him twenty-
three years to traverse that 413 miles.

LINCOLN ELLSWORTH AND N 24 JUST BEFORE THE START

Curiously enough, Peary was the first man with whom I ever
discussed the matter of using an airplane for polar work. That was
shortly before his death, and he was enthusiastic about the project.
Eight years later, in 1924, Captain Amundsen arrived in New York.
He had already announced his belief that the Polar Sea could be
crossed in a plane, and for those eight years my mind had not freed
itself of the idea. We had a long talk and, as the result, I brought
Amundsen and my father together. My father, too, became
enthusiastic and agreed to buy us two flying boats. Thus the
adventure began.

THE POLAR SEA FROM THE SKY

The island of Spitzbergen, lying just halfway between Norway
and the North Pole, is ideally situated to serve as a base for Polar
exploration. Besides its nearness to the Pole—ten degrees, or 600
nautical miles—a warm current, an offshoot of the Gulf Stream,
follows along the western and northern coasts of the island, and has
the effect of producing ice-free waters at the highest latitude in the
world. These were the principal reasons which prompted Captain
Amundsen and myself to choose Spitzbergen as a base for our
aeroplane flight to the Pole.
We wanted to be on the ground early in the spring and to make
our flight before the summer fogs should enshroud the Polar pack
and hide from view any possible landing place beneath us, for it was
our intention to descend at the Pole for observations. From April 19th
to August 24th (127 days) the sun never sets in the latitude of King’s
Bay, Spitzbergen, where we had established our base. Here one
may find growing during the long summer days 110 distinct species
of flowering plants and grasses. But from October 26th to February
17th is another story; the long Arctic winter is at hand and the sun
never shows above the horizon. Many houses have been built along
the Spitzbergen coast during the last twenty years by mining
companies who annually ship about 300,000 tons of coal, and King’s
Bay boasts of being the most northerly habitation in the world.
May 21st, 1925, was the day we had long awaited, when, with
our two Dornier-Wal flying boats we are ready to take off from the ice
at King’s Bay to start into the Unknown. We are carrying 7,800
pounds of dead weight in each plane. As this is 1,200 pounds above
the estimated maximum lift, we are compelled to leave behind our
radio equipment, which would mean an additional 300 pounds. Our
provisions are sufficient to last one month, at the rate of two pounds
per day per man. The daily ration list per man is:

Pemmican 400 gr.

Milk Chocolate 250 „
Oatmeal Biscuits 125 „
Powdered Milk 100 „
Malted Milk Tablets 125 „

At 4:15 p.m. all is ready for the start. The 450 H. P. Rolls-Royce
motors are turned over for warming up. At five o’clock the full horse
power is turned on. We move. The N 25 has Captain Amundsen as
navigator. Riiser-Larsen is his pilot, and Feucht mechanic. I am
navigator of N 24, with Dietrichson for pilot, and Omdal my
mechanic. Six men in all.
The first two hours of our flight, after leaving Amsterdam Islands,
we ran into a heavy bank of fog and rose 1,000 meters to clear it.
This ascent was glorified by as beautiful a natural phenomenon as I
have ever seen. Looking down into the mist, we saw a double halo in
the middle of which the sun cast a perfect shadow of our plane.
Evanescent and phantom-like, these two multicolored halos
beckoned us enticingly into the Unknown. I recalled the ancient
legend which says that the rainbow is a token that man shall not
perish by water. The fog lasted until midway between latitudes
eighty-two and eighty-three. Through rifts in the mist we caught
glimpses of the open sea. This lasted for an hour; then, after another
hour, the ocean showed, strewn with small ice floes, which indicated
the fringe of the Polar pack. Then, to quote Captain Amundsen,
“suddenly the mist disappeared and the entire panorama of Polar ice
stretched away before our eyes—the most spectacular sheet of
snow and ice ever seen by man from an aerial perspective.” From
our altitude we could overlook sixty or seventy miles in any direction.
The far-flung expanse was strikingly beautiful in its simplicity. There
was nothing to break the deadly monotony of snow and ice but a
network of narrow cracks, or “leads,” which scarred this white
surface and was the only indication to an aerial observer of the
ceaseless movement of the Polar pack. We had crossed the
threshold into the Unknown! I was thrilled at the thought that never
before had man lost himself with such speed—75 miles per hour—
into unknown space. The silence of ages was now being broken for
the first time by the roar of our motors. We were but gnats in an
immense void. We had lost all contacts with civilization. Time and
distance suddenly seemed to count for nothing. What lay ahead was
all that mattered now.

“Something hidden. Go and find it.

Go and look behind the Ranges—
Something lost behind the Ranges,
Lost and waiting for you. Go!”

On we sped for eight hours, till the sun had shifted from the west
to a point directly ahead of us. By all rights we should now be at the
Pole, for our dead reckoning shows that we have traveled just one
thousand kilometers (six hundred miles), at seventy-five miles per
hour, but shortly after leaving Amsterdam Islands we had run into a
heavy northeast wind, which had been steadily driving us westward.
Our fuel supply was now about half exhausted, and at this juncture,
strangely enough, just ahead of us was the first open lead of water
that was large enough for an aeroplane to land in that we had
encountered on our whole journey north. There was nothing left now
but to descend for observations to learn where we were. As Captain
Amundsen’s plane started to circle for a landing, his rear motor
backfired and stopped, so that he finally disappeared among a lot of
ice hummocks, with only one motor going.
This was at 1 a.m. on the morning of May 22nd.
The lead ran east and west, meeting our course at right angles.
It was an awful-looking hole. We circled for about ten minutes,
looking for enough open water to land in. The lead was choked up
with a chaotic mass of floating ice floes, and it looked as if some one
had started to dynamite the ice pack. Ice blocks standing on edge or
piled high on top of one another, hummocks and pressure-ridges,
was all that greeted our eyes. It was like trying to land in the Grand
Canyon.
We came down in a little lagoon among the ice-floes, taxied over
to a huge ice-cake, and, anchoring our plane to it, jumped out with
our sextant and artificial horizon to find out where we were. Not
knowing what to expect, I carried my rifle, but after our long flight I
was a bit unsteady on my legs, tumbled down into the deep snow,
and choked up the barrel. Our eyes were bloodshot and we were
almost stone-deaf after listening to the unceasing roar of our motors
for eight hours, and the stillness seemed intensified.
Looking around on landing, I had the feeling that nothing but
death could be at home in this part of the world and that there could
not possibly be any life in such an environment, when I was
surprised to see a seal pop up his head beside the plane. I am sure
he was as surprised as we were, for he raised himself half out of the
water to inspect us and seemed not at all afraid to approach, as he
came almost up to us. We had no thought of taking his life, for we
expected to be off and on our way again towards the Pole after our
observation. His curiosity satisfied, he disappeared, and we never
saw another sign of life in those waters during our entire stay in the
ice.
 Our observations showed that we had come down in Lat. 87° 44′
N., Long. 10° 20′ West. As our flight meridian was 12° East, where
we landed was, therefore, 22° 20′ off our course. This westerly drift
had cost us nearly a degree in latitude and enough extra fuel to have
carried us to the Pole. As it was, we were just 136 nautical miles
from it. At the altitude at which we had been flying just before
descending, our visible horizon was forty-six miles; which means that
we had been able to see ahead as far as Lat. 88° 30′ N., or to within
just ninety miles of the North Pole. We had left civilization, and eight
hours later we were able to view the earth within ninety miles of the
goal that it had taken Peary twenty-three years to reach. Truly “the
efforts of one generation may become the commonplace of the
next.”
When we had finished taking our observation, we began to
wonder where N 25 was. We crawled up on all the high hummocks
near by and with our field-glasses searched the horizon. Dietrichson
remarked that perhaps Amundsen had gone on to the Pole. “It would
be just like him,” he said. It was not until noon, however, of the 22nd
that we spotted them from an especially high hill of ice. The N 25 lay
with her nose pointing into the air at an angle of forty-five degrees,
among a lot of rough hummocks and against a huge cake of old blue
Arctic ice about forty feet thick, three miles away. It was a rough-
looking country, and the position of the N 25 was terrible to behold.
To us it looked as though she had crashed into this ice.
We of the N 24 were not in too good shape where we were. We
had torn the nails loose on the bottom of our plane, when we took off
from King’s Bay, so that she was leaking badly; in fact, the water was
now above the bottom of the petrol tanks. Also, our forward motor
was disabled. In short, we were badly wrecked. Things looked so
hopeless to us at that moment that it seemed as though the
impossible would have to happen ever to get us out. No words so
well express our mental attitude at that time as the following lines of
Swinburne’s:

“From hopes cut down across a world of fears,

 We gaze with eyes too passionate for tears,
Where Faith abides, though Hope be put to flight.”

That first day, while Dietrichson and I had tried to reach the N 25,
Omdal had been trying to repair the motor. We dragged our canvas
canoe up over hummocks and tumbled into icy crevasses until we
were thoroughly exhausted. The snow was over two to three feet
deep all over the ice, and we floundered through it, never knowing
what we were going to step on next. Twice Dietrichson went down
between the floes and only by hanging onto the canoe was he able
to save himself from sinking. After half a mile of this we were forced
to give up and return.
We pitched our tent on top of the ice floe, moved all our
equipment out of the plane into it, and tried to make ourselves as
comfortable as possible. But there was no sleep for us and very little
rest during the next five days. Omdal was continually working on the
motor, while Dietrichson and I took turns at the pump. Only by the
most incessant pumping were we able to keep the water down below
the gasoline tanks.
Although we had located the N 25, they did not see us till the
afternoon of the second day, which was May 23rd. We had taken the
small inflated balloons, which the meteorologist had given us with
which to obtain data regarding the upper air strata, and after tying
pieces of flannel to them set them loose. We hoped that the wind
would drift them over to N 25 and so indicate to them in which
direction to look for us. But the wind blew them in the wrong
direction, or else they drifted too low and got tangled up in the rough
ice.
Through all that first day the wind was blowing from the north
and we could see quite a few patches of open water. On the second
day the wind shifted to the south and the ice began to close in on us.
It was as though we were in the grasp of a gigantic claw that was
slowly but surely contracting. We had a feeling that soon we would
be crushed.
 On the third day, May 24th, the temperature was -11.5 c., and we
had trouble with our pump freezing. The two planes were now slowly
drifting together, and we established a line of communication, so that
we knew each other’s positions pretty well. It is tedious work,
semaphoring, for it requires two men: one with the flag, and the other
with a pair of field-glasses to read the signals. It took us a whole
hour merely to signal our positions, after which we must wait for their
return signals and then reply to them.
On this day, after an exchange of signals, we decided to try to
reach Amundsen. We packed our canvas canoe, put it on our
sledge, and started across what looked to us like mountainous
hummocks. After only going a few hundred yards we had to give up.
The labor was too exhausting. With no sleep for three days, and only
liquid food, our strength was not what it should have been. Leaving
our canvas canoe, we now made up our packs of fifty pounds each,
and pushed on. We may or we may not return to our plane again.
According to my diary we traveled the first two miles in two hours
and fifteen minutes, when we came upon a large lead that separated
us from the N 25 and which we could see no way to cross. We talked
to them by signal and they advised our returning. So, after a seven-
hour trip, we returned to our sinking plane, having covered perhaps
five and one half miles in about the same length of time it had taken
us to fly from Spitzbergen to Lat. 87.44. Arriving at our plane, we
pitched camp again and cooked a heavy pemmican soup over our
Primus stove. Dietrichson gave us a surprise by producing a small
tin of George Washington coffee. We took some of the pure alcohol
carried for the Primus stove and put it into the coffee, and with pipes
lighted felt more or less happy.
As we smoked in silence, each with his own thoughts,
Dietrichson suddenly clasped his hands to his eyes, exclaiming:
“Something is the matter with my eyes!” He was snow-blind, but
never having experienced this before, did not know what had
happened to him. We had been careful to wear our snow-glasses
during most of the journey, but perhaps not quite careful enough.
After bandaging Dietrichson’s eyes, Omdal and I put him to bed and
then continued with our smoking and thoughts. It seems strange,
when I think back now, that during those days nothing that happened
greatly surprised us. Everything that happened was accepted as part
of the day’s work. This is an interesting sidelight on man’s
adaptability to his environment.
All our energies were now being bent in getting the N 24 up onto
the ice floe, for we knew she would be crushed if we left her in the
lead. The whole cake we were on was only about 200 meters in
diameter, and there was only one level stretch on it of eighty meters.
It was laborious work for Dietrichson and myself to try to clear the
soggy wet snow, for all we had to work with was one clumsy home-
made wooden shovel and our ice-anchor. As I would loosen the
snow by picking at it with the anchor, Dietrichson would shovel it
away.
Looking through our glasses at N 25, we could see the
propellers going, and Amundsen pulling up and down on the wings,
trying to loosen the plane from the ice, but she did not budge. On the
morning of May 26th, Amundsen signaled to us that if we couldn’t
save our plane to come over and help them. We had so far
succeeded in getting the nose of our plane up onto the ice-cake, but
with only one engine working it was impossible to do more. Anyway,
she was safe now from sinking, but not from being crushed, should
the ice press in on her. During the five days of our separation the ice
had so shifted that the two planes were now plainly in sight of each
other and only half a mile apart. During all that time the ice had been
in continual movement, so that now all the heavy ice had moved out
from between the two camps. We signaled to the N 25 that we were
coming, and making up loads of eighty pounds per man, we started
across the freshly frozen lead that separated us from our
companions. We were well aware of the chances we were taking,
crossing this new ice, but we saw no other alternative. We must get
over to N 25 with all possible speed if we were ever to get back
again to civilization.
With our feet shoved loosely into our skis, for we never fastened
them on here for fear of getting tangled up, should we fall into the
sea, we shuffled along, slowly feeling our way over the thin ice.
Omdal was in the lead, myself and Dietrichson—who had recovered
from his slight attack of snowblindness the next day—following in
that order. Suddenly I heard Dietrichson yelling behind me, and
before I knew what it was all about Omdal ahead of me cried out
also and disappeared as though the ice beneath him had suddenly
opened and swallowed him. The ice under me started to sag, and I
quickly jumped sideways to avoid the same fate that had overtaken
my companions. There just happened to be some old ice beside me
and that was what saved me. Lying down on my stomach, partly on
this ledge of old ice, and partly out on the new ice, I reached the skis
out and pulled Dietrichson over to where I could grab his pack and
partly pull him out onto the firmer ice, where he lay panting and
exhausted. Then I turned my attention to Omdal. Only his pallid face
showed above the water. It is strange, when I think that both these
Norwegians had been conversing almost wholly in their native
tongue, that Omdal was now crying in English, “I’m gone! I’m
gone!”—and he was almost gone too. The only thing that kept him
from going way under was the fact that he kept digging his fingers
into the ice. I reached him just in time to pull him over to the firmer
ice. I reached him just before he sank and held him by his pack until
Dietrichson could crawl over to me and hold him up, while I cut off
the pack. It took all the remaining strength of the two of us to drag
Omdal up onto the old ice.
Our companions could not reach us, neither could they see us,
as a few old ice hummocks of great size stood directly in front of
N 25. They could do nothing but listen to the agonizing cries of their
fellow-men in distress. We finally succeeded in getting over to our
companions, who gave us dry clothes and hot chocolate, and we
were soon all right again, except for Omdal’s swollen and lacerated
hands. Both men had lost their skis. In view of the probability of
being forced to tramp to Greenland, four hundred miles away, the
loss of these skis seemed a calamity.
I was surprised at the change only five days had wrought in
Captain Amundsen. He seemed to me to have aged ten years. We
now joined with our companions in the work of freeing the N 25 from
her precarious position. As stated before, when Captain Amundsen’s
plane had started to come down into the lead, his rear motor back-
fired, and he was forced to land with only one motor working, which
accounted for the position which we now found N 25 in. She lay half
on and half off an ice floe; her nose was up on the cake and her tail
down in the sea. Coming down thus had reduced her speed and
saved her from crashing into the cake of old blue ice, which was
directly ahead. It seemed amazing that whereas five days ago the
N 25 had found enough open water to land in, now there was not
enough to be seen anywhere sufficient to launch a rowboat in. She
was tightly locked in the grip of the shifting ice.

N 25 ABOVE THE POLAR PACK JUST BEFORE LANDING AT 87° 44′

A most orderly routine was being enforced at Amundsen’s camp.
Regular hours for everything—to work, sleep, eat, smoke and talk;
no need to warn these men, as so many explorers had been
compelled to do, not to give one another the story of their lives, lest
boredom come. These Norwegians have their long periods of silence
in which the glance of an eye or the movement of a hand takes the
place of conversation. This, no doubt, accounts for the wonderful
harmony that existed during the whole twenty-five days of our
imprisonment in the ice. One might expect confusion and
disorganization under the conditions confronting us. But it was just
the reverse. We did everything as if we had oceans of time in which
to do it. It was this calm, cool, and unhurried way of doing things
which kept our spirits up and eventually got us out of a desperate
situation. No one ever got depressed or blue.

N 24 AND OUR ARCTIC HOME

We elected Omdal our cook. Although we felt better nourished
and stronger after our noon cup of pemmican broth, it was always
our morning and evening cup of chocolate that we looked forward to
most. How warming and cheering that hot draught was! Captain
Amundsen remarked that the only time we were happy up there was
when either the hot chocolate was going down our throats, or else
when we were rolled up in our reindeer sleeping bags. The rest of
the time we were more or less miserable, but never do I remember a
time when we ever lost faith! The after-compartment of our plane—a
gaunt hole—served as kitchen, dining-room and sleeping-quarters,
but it was draughty and uncomfortable, and it seemed always a relief
to get out into the open again after our meals. The cold duralumin
metal overhead was coated with hoarfrost which turned into a steady
drip as the heat from our little Primus stove, together with that from
our steaming chocolate, started to warm up the cabin. Feucht always
sat opposite me—I say sat, but he squatted—we all squatted on the
bottom of the plane with our chocolate on our knees. I remember
how I used to covertly watch him eating his three oatmeal wafers
and drinking his chocolate. I always tried to hold mine back so as not
to finish before him. I had the strange illusion that if I finished first it
was because he was getting more to eat than I. I particularly recall
one occasion, two weeks later, after we had cut our rations in half,
when I purposely hid my last biscuit in the folds of my parka, and the
satisfaction it gave me to draw it out and eat it after Feucht had laid
his cup aside. It was the stirring of those primitive instincts which,
hidden beneath the veneer of our civilization, lie ever ready to assert
themselves upon reversion to primitive conditions. We smoked a
pipe apiece of tobacco after each meal, but unfortunately we had
taken only a few days’ supply of smoking stuff. When that went, we
had to resort to Riiser-Larsen’s private stock of rank, black chewing
twist. It took a real hero to smoke that tobacco after moistening it so
as to make it burn slower and thus hold out longer. It always gave us
violent hiccoughs.
We were compelled to give up our civilized habits of washing or
changing our clothes. It was too cold to undress, and we could not
spare the fuel to heat any water after our necessary cooking was
done.
During all our stay in the ice I never saw Captain Amundsen take
a drink of water. I was always thirsty after the pemmican, and when I
called for water, he said he could not understand how I could drink
so much water.
Captain Amundsen and I slept together in the pilot’s cockpit,
which we covered over with canvas to darken it at night. I was never
able to get used to the monotony of continuous daylight and found it
very wearing. With the exception of Riiser-Larsen the rest of the men
slept on their skis stretched across the rear-compartment to keep
them off the metal bottom. Riiser-Larsen had the tail all to himself,
into which he was compelled to crawl on hands and knees.
It took us a whole day to construct a slip and work our plane up
onto the ice-cake. The work was exhausting on our slim rations, and,
besides, we had only the crudest of implements with which to work:
three wooden shovels, a two-pound pocket safety-ax, and an ice
anchor. Through hopeless necessity we lashed our sheath-knives to
the end of our ski-sticks, with which we slashed at the ice. It is
remarkable, when one considers the scant diet and the work we
accomplished with these implements! Captain Amundsen
conservatively estimates that we moved three hundred tons of ice
during the twenty-five days of our imprisonment up there in order to
free our plane.
The floe we were on measured 300 meters in diameter, but we
needed a 400-meter course from which to take off. Our best chance,
of course, would be to take off in open water, but the wind continued
to blow from the south, and the south wind did not make for open
water.
Riiser-Larsen was tireless in his search for an ice floe of the right
dimensions. While the rest of us were relaxing, he was generally to
be seen on the skyline searching with that tireless energy that was
so characteristic of him. Silent and resourceful, he was the rock on
which we were building our hopes.
The incessant toil went on. On May 28th the N 25 was safe from
the screwing of the pack-ice. On this day we took two soundings,
which gave us a depth of 3,750 meters (12,375 feet) of the Polar
Sea. This depth corresponds almost exactly to the altitude of Mont
Blanc above the village of Chamonix. Up to this time our only
thought had been to free the plane and continue on to the Pole, but
now, facing the facts as they confronted us, it seemed inadvisable to
consider anything else but a return to Spitzbergen. The thermometer
during these days registered between -9° c. and -11° c.
On May 29th Dietrichson, Omdal and I, by a circuitous route,
were able to reach the N 24 with our canvas canoe and sledge. We