Getting Serious: Part III

Human Error Causes & Consequences

By STEPHEN NEWELL, JD, DEE WOODHULL, CIH, CSP and ROSEMARIE LALLY, JD

R esearch conducted on human error, its causes, and consequences helps to elucidate this risk relationship. Human error is a symptom of trouble deeper inside a system, according to author Sydney Dekker. To explain failure, we must understand how workers’ assessments and actions made sense at the time given the circumstances that surrounded them. Workers themselves do not usually cause serious incidents. They can trigger latent conditions existing in systems, processes, procedures, and expectations on the job site, as Todd Conklin explains in “Pre-Accident Investigations.” Serious injuries often have multiple causal factors such as inadequate tools, equipment, and processes, James Reason notes in “Managing the Risks of Human Error.” These elements may be present for many years before combining with local circumstances and active failures to penetrate the system’s layers of defenses. As Conklin says, an accident can be defined as an unexpected combination of normal variability.

Human error is not a cause, but rather a symptom of a system that needs to be redesigned, offers Nancy Leveson in “Engineering a Safer World.” All behavior is affected by context, or the system in which it occurs. Tackling operator error requires examining the system in which people work, particularly the design of equipment, usefulness of procedures, and existence of goal conflicts and production pressures. Don’t punish the operator who made a mistake, explore why the system allowed – or failed to accommodate – a mistake and work to improve the system, contends Chris Hart, chairman of the National Transportation Safety Board.

The Truth: People Are Fallible

The principles of Human and Organizational Performance (HOP) focus on the truth that even the best people make mistakes.

Still, situations in which errors are likely to be made are predictable, manageable, and preventable. Why? Individual behavior is influenced by organizational processes and values. Management’s response to failure matters. Both HOP principles and characteristics of High Reliability Organizations (HRO) have a profound impact on overall risk and serve as two sides of the same coin to prevent fatalities and serious injuries. HOP issues focus on the context in which employees must address the hazards associated with their operation; HRO issues focus on organizational capacity to effectively deal with those hazards. Each approach is critical to prevention.The five characteristics of HROs, as discussed by Weick and Sutcliffe in “Managing the Unexpected,” include:

Preoccupation with failure: Error reporting is encouraged and lapses are treated as a symptom that something may be wrong with the system.

Reluctance to simplify: Organizations know that the world they face is complex, unstable, and unpredictable.

Sensitivity to operations: Organizations are attentive to the front line where the real work gets done.

Commitment to resilience: Organizations detect and contain problems, and bounce back.

Deference to expertise: People with the most expertise are valued regardless of rank.

To achieve high reliability performance:

identify and assess risks;

identify and understand points of human interaction with hazards in the process;

provide high levels (or multiple layers) of control at critical steps;

do not expect people never to make a mistake or rely on them to single-handedly control the risk;

continuously improve by learning from data such as precursor events, near misses, etc.;

understand human performance issues and organizational characteristics that can provoke errors and/or undermine controls.