Hi, and welcome back. In the last issue, we looked at risk assessments and why our most serious injuries didn’t come from the most dangerous things we’ve done.
Although this might seem counter-intuitive it’s understandable—or at least it’s very easy to understand why most people do not focus on the “human error” component or consider it to be the most important. We’ve been led in the wrong direction—for a long, long time—ever since we were little kids. Which is unfortunate. Driver error is over 95 percent of primary causation vs. weather, mechanical failure (brakes), etc. With all the statistics available, you’d think human error would have become a mandatory component in risk assessment! But that’s how strong some beliefs/paradigms are.
Other paradigms, beliefs or perspectives besides this misconception of “danger” are also inaccurate. Conceptually, the idea that there would be more close calls than minimal (first-aid) injuries; more minimal injuries than minor; more minor than major and more major than fatal was totally plausible, it made sense and there were statistics to prove it. But the next part, that the only difference between minimal and minor, or minor vs. major was just luck—provided the overall amount of hazardous energy stayed the same—wasn’t questioned or challenged very much.
But this line of thinking ignores the number one piece of safety knowledge we do possess: nobody is ever trying to get hurt! Which means we will also try very hard, even if it’s just a reflex, to avoid getting hit, or falling down or banging our head or crashing the car, etc., etc. In other words, we are not totally defenseless.
Luck isn’t a factor
The difference between minimal and major isn’t luck; there is indeed an assignable cause—even for most of the ones that tend to get called “fluke accidents.” To get to the bottom of all this, let’s go back to what has happened to us: Our personal risk pyramid.
We’ve all had 5-10,000 cuts, bruises, bumps and scrapes, but most of us only had 5-10 or so that were serious; or if we were at work, would be called a “recordable” injury. At 1000:1 we should be looking for an assignable cause vs. random chance or pure luck. But popular thinking goes in the other direction, giving luck even more credit, by calling some cases “fluke accidents.”
Most people call two types of “extremely unlikely” events fluke accidents. The first is just a very unlikely occurrence—getting hit in the head by a meteorite. The other is a very uncommon outcome from a very common occurrence—someone losing their balance, falling backwards, hitting their head and never getting up again. Think of the old risk matrix: these would be in the bottom left-hand corner which, ironically, is usually colored green.
Your personal risk pyramid
Look at all of the serious incidents and where most of them occurred -- in the middle of the matrix (see Figure #1—Actual Outcomes) -- interesting patterns or similarities in terms of contributing factors emerge. First, keep in mind that more than 95 percent of these cases are in the “Self-Area” discussed in the previous two articles. And eyes not on task and mind not on task cause problems, but what happens if both errors are made at the same time? To help illustrate the importance of each, and then when both of them occur together, think back to the personal risk pyramid or to what’s actually happened to you (see Figure #2 for reference).
Can you think of one time (not including sports) when you’ve been hurt when you were thinking about what you were doing, and the risk of what you were doing at the exact instant when you got hurt? It’s hard to think of even one example—if it was in the Self-Area. So, when it comes to getting hurt or not getting hurt, regardless of what you are doing (unless you’re not moving or nothing around you is moving), paying attention or not paying attention will be the most important, deciding factor. Of course, there may always be issues with training or skill, but since mind not on task is involved in over 95 percent of all injuries—whether they be serious, minor or minimal—that has been the deciding factor in our lives so far.
Eyes not on task
Mind on task or mind not on task is king. But how important is the next critical error: eyes not on task?
Think about all the serious injuries you’ve sustained (where the unexpected event was in the Self-Area). When you got hurt badly, were you looking at what you were doing? Could you see where you were going? And did you look for what could be coming at you (line-of-fire), or what could cause you to lose your balance, traction or grip?
In other words, did you have your eyes on task—or not?
The majority of serious injuries happened when both critical errors are made at the same time. They weren’t thinking about what they were doing, and at least for a moment, they weren’t looking either. When you’re not looking and you’re not thinking, you won’t get the benefit of your reflexes. Reflexes can be the difference between a near miss or a fatality.
How often have your reflexes prevented an accidental injury? How many times have you had to hit the brakes suddenly or jerk the steering wheel to avoid hitting another car, truck or pedestrian? How many times have you regained your balance without actually falling? Hundreds, thousands?
Preventing serious injuries
Thankfully most of us can count all our serious injuries. So, when you think about the stitches, broken bones, concussions, serious burns, etc., did you get the benefit of your reflexes? (See Figure #2) Because if you didn’t see it coming, then you probably didn’t get a chance to hit the brake, jerk the steering wheel, duck your head, get a hand down to brake your fall, etc. So instead of a glancing blow, it’s a direct hit and stitches or a concussion.
Both critical errors: eyes not on task and mind not on task are involved in a very high percentage of all serious injuries at work, at home, in the community or on the road. If we could improve people’s skills and habits with eyes on task it would improve the likelihood that they would get a reflex, and that, in most cases, would be enough to prevent a serious injury. It might not prevent the incident from happening, but reflexes do a great job of keeping it from being more severe (see Figure #3).
Almost all serious accidents can be prevented if we can get people to improve their habits with eyes on task. For example: looking for things that could cause you to lose your balance, traction or grip, looking for line-of-fire potential before moving; looking up before you stand up to avoid banging your head; and moving your eyes before you move your body, feet, hands or car (vehicle), etc.
Good habits aren’t enough
Good habits can compensate for complacency leading to mind not on task, but they don’t prevent it. That’s impossible if you know how to do something well. Other critical error reduction techniques will help to get your mind back on task if you’ve drifted off or start driving/working on autopilot. And if you add enough rushing, frustration or fatigue to the equation, those states can override good habits; which means we will need more than just improved safety-related habits to deal with all four states.
There are four critical error reduction techniques people need to know and use to prevent critical errors. For now, the main paradigm shift is that mind not on task is a contributing factor in more than 95 percent of all injuries; for a very high percentage of the serious injuries, eyes not on task is also a contributing factor. This is why we didn’t get the benefit of our reflexes, making the injury so uncommonly severe, or so seemingly unlucky that is gets called a fluke accident.
Next issue: reaching equilibrium—why everyone thinks they’re safe enough.