How to Recognize a Basic Failure

The bus driver walked away from the accident in Prospect Lefferts Garden in a daze, his wrist aching and bloody. He had thirteen years of experience as an operator with the Metropolitan Transportation Authority in New York City. Now his forty-foot blue and yellow bus was crammed into the bottom of a Brooklyn brownstone. He told witnesses congregated on the sidewalk that his foot had caught between the brake and the accelerator, and had lost control of the bus. It had lurched forward, crashing into other vehicles and then the side of the building, shattering the glass windows on a first-floor doctor's office. Sixteen passengers were injured, none seriously. A video released later showed that the driver had held shopping bags between his feet.

The accident was a classic basic failure.

Although it was against the rules to store any items near the pedals, on the afternoon of June 7, 2021, the fifty-five-year-old-driver took a chance with the shopping bags. Investigators found no mechanical defects in the vehicle. The bus had been travelling along its normal route. Weather and visibility were fine. The accident was attributable to a single, easily identifiable cause - the driver's stuck foot.

The accident presents two characteristic features of basic failures: They occur in known territory. They tend to have a single cause.

Known territory

To be classified as a basic failure, the mistake must occur in an area where knowledge already exists about how to achieve a desired result. The driver whose bus crashed into the side of the building broke the safety rules by placing the shopping bags between his feet. Similarly, when a chair collapses because you didn't follow the assembly instructions, the broken legs on the floor attest to a basic failure. Guidelines, rules, previous research, and knowledge gleaned from someone you know are illustrations of known territory. If you can find instructions on the internet, it's known territory. In short, existing knowledge can be put to use without magic or miracle. Access or training is available. Building codes and safety regulations codify known territory to prevent failure and are often put into place in response to a prior failure.

Simply put, a failure is basic when errors happen because we do not use knowledge that was available - whether due to inattention, neglect, or overconfidence.

What if you make a mistake the first time you bake cookies or build a coffee table? Get lost in a city where you do not speak the language? The failures that might ensue are basic because knowledge of how to bake cookies, build coffee tables, or get around the city was available. Get a recipe, follow the instructions, use a map.

Single Cause

The bus accident was a basic failure with a single cause - the driver's stuck foot. A phone died because it ran out of battery power. A cake was inedible because salt was substituted for sugar. A plane crashed because the deicer was turned off on an icy day. A bank lost money because the correct boxes were not checked.

Sometimes, failures that initially appear to have a single cause turn out to be embedded in a complex web of causes. For example, the tragic port explosion that devastated Beirut in 2020 was initially attributed to a simple cause: 2,750 tons of chemical fertilizer improperly stored. However, further information implicated poor safety procedures, lack of oversight et al.

This article on "How to Recognize a Basic Failure" is excerpted from Amy Edmondson's book titled "Right Kind of Wrong"