OH those Human ErrorSafety Incidents

When you Investigate the Cause was it the worker or the plan that failed?

TO Error is HUMAN

TYPES

Safety's Three Major Concerns

When you have incidentsdo you check?

When you do inspection do you consider

Do you think about worker maturity and culture?

Part of the Scope

Who knows what and why

Does the WHOLE TEAMknow the values listed

Does the team help or hinder in these questions

Your Risk Values to the investigation

Does the team look at

Common is to everyone

Who talked to WHOM and When

Leadership

A Simple Model

Performance outcome Y is a

function of factors X.

PerformanceOutcome

Factors AffectingOutcome Y

Y = f (x)

Why a Human Performance Improvement

Approach?

80% Human

Error30%

Individ

ual

20%

Equipment

Failures

Human Error

Unwanted

Outcomes70%

Latent

Organiza

tion

Weaknes

ses

Facts about Human Error

• It thrives in every industry

• It is a major contributor to events and unwanted outcomes

• It is costly, adverse to safety and hinders productivity

• The greatest cause of human error is weaknesses in the organization, not lack of skill or knowledge

• Error rates can never be reduced to zero

• Consequences of errors can be eliminated

Principles

1. People are fallible, and even the best make

mistakes.

2. Error-likely situations are predictable,

manageable, and preventable.

3. Individual behavior is influenced by

organizational processes and values.

4. People achieve high levels of performance

based largely on the encouragement and

reinforcement received from leaders, peers,

and subordinates.

5. Events can be avoided by understanding

the reasons mistakes occur and

applying the lessons learned from past

events.

Plant

Worker

Processes Values

Individual

• Limited short-term memory• Personality conflicts

• Mental shortcuts (biases)• Lack of alternative indication

• Inaccurate risk perception (Pollyanna)• Unexpected equipment conditions

• Mindset (“tuned” to see)• Hidden system response

• Complacency / Overconfidence• Workarounds / OOS instruments

• Assumptions (inaccurate mental picture)

• Confusing displays or controls

• Habit patterns• Changes / Departures from routine

• Stress (limits attention)• Distractions / Interruptions

Human NatureWork Environment

• Illness / Fatigue• Lack of or unclear standards

• “Hazardous” attitude for critical task• Unclear goals, roles, & responsibilities

• Indistinct problem-solving skills• Interpretation requirements

• Lack of proficiency / Inexperience• Irrecoverable acts

• Imprecise communication habits• Repetitive actions, monotonous

• New technique not used before• Simultaneous, multiple tasks

• Lack of knowledge (mental model)• High Workload (memory requirements)

• Unfamiliarity w/ task / First time• Time pressure (in a hurry)

Individual CapabilitiesTask Demands

Error Precursorsshort list

Limitations of Human Nature

Avoidance of mental strain

Inaccurate mental models

Limited working memory

Limited attentionresources

Pollyanna effect

Mind set

Difficulty seeing own errors

Limited perspective

Susceptible to emotion

Focus on goal

Human Information Processing

Shared

Attention

Resources

ThinkingSensing Acting

Information

Flow Path

Performance Modes--Attending Problems

Familiarity (w/ task)Low High

High

Low

Att

en

tio

n (

to t

ask)

Inattention

Misinterpretation

Inaccurate

Mental Picture

Blame

Cycle

Human

Error

Less

communication

Management less

aware of jobsite

conditions

Reduced trustLatent organizational

weaknesses persist

Individual counseled

and/or disciplined

More flawed defenses

& error precursors

The Blame Cycle

Human Performance Tools

• Critical Steps

• Enhanced Pre-Job Briefing

• Peer Check

• Self Check

• Independent Verification

• Error Traps

• Just Culture

• Effective Communication

• Questioning Attitude

• Feeling of Uneasiness

• Enhanced Turnover

• 3 way communication

• Error Precursors

• Performance/Error Modes

• Devils Advocate

• Place keeping

• Poka Yoke

• SAFE Dialogue

• Discovery Clock

• STAR

• Training

Yes it really is part of your plan and so are you

Me, Bob and You!

Create the right culture

• Instead, companies should try to create a culture of openness around the reporting of incidents, and identify in advance certain divisions or groups of employees where errors are more likely to occur. Even then companies can still be seriously affected by people making mistakes, brought about by a change in personnel, regulation that affects workplace protocols, or even by an error occurring within the supply chain or among contractors.