Assessing hazards & human error
Rethinking traditional safety
This will be a series of short articles designed to provide a different perspective—a paradigm shift -- in terms of how most of you think about industrial safety. And how most of you think about accidental injury causation in general. Questions you will be asked in these articles have been asked to more than three million people in 66 countries. I have personally asked the questions to more than 125,000 people at training sessions and conferences. During the past five years we’ve also collected data with audience response systems. Despite the improvement in data collection, the answers and the percentages really haven’t changed since we first started asking these questions 20 years ago.
Some of the paradigm shifts I’ll discuss are controversial or cause arguments, especially with those who accept a lot of the traditional “doctrine” about industrial safety management at face value. But if you can keep an open mind as you go through the series, you’ll have a much broader perspective on accidental injury causation, and be much better equipped to answer questions like:
- Why does anybody ever get hurt when nobody ever wants to?
- Why do experts and experienced workers get hurt and killed?
- Why parents who love their children can’t keep them from getting hurt (especially when they are young).
Let’s begin by asking a question: when you think about the people you know well -- your family, friends and coworkers -- and all of their serious injuries (excluding sports), were they caused “primarily” by hazards or by two critical human errors occurring at the same time?
Paradigm shift #1: Hazards or human error?
If you ask people what’s more important, hazards or human error, you will hear many different perspectives...
Many managers, including some safety professionals, believe industrial safety is all about, or at least mostly about, the hazards, things inherently dangerous like a flame, toxic chemical or rotating saw blade -- something that needs to be contained, guarded or controlled. From a regulator’s point of view, hazards and controlling or guarding of them is basically what standards are all about. So it’s easy enough to see why some managers and safety professionals believe hazards are so important.
Another consideration: engineering controls, ventilation systems, guarding and personal protective equipment all cost money. Since these costs do not directly improve production or quality, it’s easy to understand why many managers think they are a “sunk cost” or just a “cost of doing business.” This reinforces the paradigm that industrial safety is primarily about identifying and mitigating hazards.
Other people will say human error is inevitable; that it’s a result, not a cause; and it is not important in a well-managed safety system. But these folks still will go home and tell their kids to be “careful” not to commit a human error. Or if they do get hurt, try to be “more careful” next time. Are they hypocrites or using the wrong paradigms or belief systems?
Let’s look at the paradigms or beliefs involved here. Say someone thinks a hazard is inherently dangerous, such as a flame, toxic chemical, etc. OK, have them look at a concrete bridge on a highway and ask, “Is that bridge a hazard?” Most will inspect the bridge and if there’s nothing structurally wrong with it, they’ll say no. “But what if you hit that concrete at 60 mph on a motor bike?” It could kill you.
So I’m not talking only about inherently dangerous hazards. We need to talk about hazardous energy—which includes kinetic energy (see Figure #1). In terms of potential for harm, this could be if something hits you (line-of-fire), or if you hit it or you move into it (eyes not on task; mind not on task; loss of balance, traction or grip).
Think about forklifts and pieces of mobile equipment, or people riding bikes or driving cars. It’s their eyes and their minds that tell the driver or the operator that they could be moving into a potential incident.
Whenever people are moving, eyes on task and mind on task are “primary” not secondary in terms of preventing incidents and accidental injuries. In terms of inherently dangerous hazards such as a toxic chemical or a sharp edge, unless you contact the hazard there won’t be an injury. Still, you wouldn’t become exposed or move into it if you could see it or you were thinking about it.
Eyes and mind on task are very important.
Eyes not on task and mind not on task are almost always contributing factors with these kinds of hazardous energy (movement) injuries. With inherently dangerous static hazards it’s arguable that guarding the saw blade and containing the chemical is just as important or more important.
In almost every unintentional incident, one or two of the critical human errors were also involved. For example: If a tradesman has just finished welding something and it is still red hot, the welder would not touch it with his bare hand if he was looking at the red hot metal. But if he took off his gloves, and turned without looking because somebody called him, he could touch it by mistake. Or if the metal had cooled down so it wasn’t red hot he could touch it if he wasn’t thinking that it could still be very hot. The only other way he could contact the hot metal is if he lost his balance and – in an effort to regain his balance or stop himself from falling – his hand contacts the hot metal by mistake as a result of his reflex action.
Four critical errors alone or in combination are contributing factors in almost all incidents and injuries. Two have been mentioned: eyes not on task and mind not on task. (The other two will be discussed in future articles.) One or both of these first two critical errors can cause someone to move into the line-of-fire or to lose their balance, traction or grip. So safety is not just about inherently dangerous hazards. It’s also about potentially hazardous energy—which includes kinetic energy. Movement is important, making eyes and mind on task important.
Eyes not on task and mind not on task are involved in almost every serious injury.
These two critical errors are almost always involved in incidents involving welding; climbing a ladder; walking or running down stairs; cutting, chopping, sawing; driving or riding; cleaning or washing. This makes sense because we are never trying to get hurt anywhere, anytime, no matter what we’re doing. But it is certainly possible to get hurt on a stairway when there’s nothing wrong with the stairway or no visible hazard such as a cord or a spill.
So when it comes to the question, “What’s more important?” it’s obvious that human error is hardly unimportant whether you have a well-managed safety system or not. But the “what’s more important?” question of hazards or human error goes ever further. Hazards involve the “sunk costs” of engineering controls, PPE, etc. They don’t affect top line revenue. But human error does have a more apparent cost, even if it’s just a simple mind not on task error causing a sales rep to miss a lunch meeting.
Always a factor
It’s hard to think of a job or a task where human error or inattention would not be a factor. If you could improve eyes on task and mind on task you would improve much more than safety or the bottom line. You would improve production, quality and customer relations. That’s a big paradigm shift for a lot of people, especially the managers who think safety is a sunk cost.