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PETERSEN'S PAGE: To reduce human error...

November 1, 2005
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By the time this article is printed in ISHN, I will have been in safety work for a little more than 50 years — I hope 50 years of learning, not one year’s learning repeated 50 times.

Scott Geller wrote in ISHN several years ago about some of his feelings following surgery — about looking at life and reassessing what’s important and what isn’t. I had a similar experience in 2004. A series of events led to surgery that the surgeon prefaced by saying, “Do it or be gone in a year.” Afterward, a bunch of questions popped out at me, such as: Where do I go from here — in my personal and family life, in my faith and relationships, in my business thrusts?

After a while I began to question the profession of safety and asked questions like:

If we are doing the right “stuff,” why have our results plateaued in lost-time injuries and worsened in days lost?

When research from aviation, medicine, communications and other fields has identified many of the organizational causes of human error, why does occupational safety ignore such data?

Human error is a subject near and dear to my heart. As an industrial engineering undergraduate, I studied work simplification, plant layout and motion study, not for the purpose of reducing error, but rather to increase productivity. Years later, I became acquainted with human factors concepts in graduate work in psychology. It seemed that this was a natural focus for the safety profession. That was in 1971, and for some reason, the profession found OSHA and its standards to be considerably more interesting.

From a human factors standpoint, it seems that safety has lost 30+ years of possible progress in reducing human error.

Causes of error

An injury or other type financial loss to a company is the result of 1) a system failure, and 2) a human error. Systems failure relates to issues traditional safety management covers, such as: How are those responsible for safety measured for performance, and what systems are used for inspections to find out what went wrong?

The second and always present cause of an incident or accident is human error. Human error results from one or a combination of three factors: 1) overload; 2) a decision to err; and 3) traps that are left for the worker in the workplace.

Overload: To deal with overload as an accident cause, you must look at an individual’s capacity, workload and current state. To deal with overload as an organizational cause, you must identify the controls available for dealing with capacity, workload and state.

A human being’s capacity refers to physical, physiological and psychological endowments; the current condition of all three; current state of mind; current level of knowledge and skill relevant to the task at hand; and possible temporarily reduced capacity owing to factors such as drug or alcohol use, pressure or fatigue.

Load refers to the task and what it takes physically, physiologically and psychologically to perform it. Load also refers to the amount of information processing a person must perform; the working environment; the amount of worry, stress and other psychological pressure; and the person’s home life and total life situation.

In today’s environment, there has never been more overload on workers and managers. This is due to trends such as downsizing, outsourcing, increase in span of control, employee ownership concepts, self-directed work teams and employee involvement.

Decision to err: In some situations it seems logical to a worker to choose the unsafe act. Reasons might include:

1) Motivational inputs — peer pressure, pressure to produce and many other factors — might make unsafe behavior seem preferable.

2) Mental condition.

3) Low perceived probability — the worker just doesn’t believe he or she will have an accident.

Traps: A worker can err because his or her work situation is incompatible with their physique or prior work experience. A second trap can be the design of the workplace — it is conducive to human error. A third trap is the culture of the organization — what behaviors it encourages or discourages. Certain cultures are “error-provocative.”

This leads to an important conclusion: much more progress can be made by changing the culture than by preaching or disciplining. Human errors at lower levels of the organization are symptoms of things that are wrong in the organization at higher levels.

Human error can be reduced by changing the situation. This change is accomplished by assistance from the outside (staff safety, line management), working within a corporate philosophy, through study of the situation and through participation of the individual worker.

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