We all work hard at preventing accidents in the industrial workplace. It’s one of the top priorities and can indeed affect the financial health of any business.
When an accident does happen, whether there is property damage, production ramifications, or worker health issues or safety involved, a root cause analysis should be and normally is performed. It’s important to understand what caused the accident to prevent it from happening again. We constantly strive to make our workplaces as safe as possible for everyone.
Accidents do happen - that’s a given. Our job is to lessen the frequency and lower the impact on personnel, property, and production.
In many cases, industrial accidents can be traced back to human error. However, sometimes we don’t determine the exact cause and may stop short of the real issue to be resolved.
What Is Human Error in Industrial Accident Root Cause Analysis?
Human error can simply be defined as those mishaps or mistakes caused by a person, not a machine. However, it’s not really that simple. While it may be easy to say that “Joe” did it … that it’s his fault, the issue can’t be dismissed so easily. If you dig down into the reason behind the reason, the real underlying problem may not be that person’s fault - at least not entirely. It could be more involved.
Human error is often cited as the primary cause or contributing factor in accidents and disasters. The industries affected run the gamut from nuclear power and aviation to manufacturing and medicine.
So, preventing human error is seen as a major contributor to the reliability and safety of any system, whether simple or complex.
What Root Cause Analysis is (and what it's not)
A Root Cause Analysis (RCA) is an investigation of a workplace accident to pinpoint the exact cause of the incident. Taking into account all the aspects of the accident–people involved, environment, equipment status, etc.–the analysis is a problem solving tool used to prevent similar future incidents.
That’s important to understand. An RCA is not used to place blame, but discover cause. For the RCA to be accurate and valuable, everyone involved must be on board and comfortable with the process. This includes the workers directly involved with the incident.
When delving into the root cause of any industrial accident instigated by human error, understand that there are two possible approaches: the “person” approach, and the “system” approach. The approach you use will affect the outcome of the investigation.
Using an incorrect approach to Root Cause Analysis may eliminate the immediate symptoms of the accident, but not fix the underlying actual cause. Properly done, the RCA can prevent future incidents. Improperly done sweeps the real problem under the rug, so to speak.
The problem could very well show up again.
Your Company’s Role in Preventing Workplace Accidents Caused by Human Error
Most of us should agree - worker safety is job #1. There should be nothing more important than the safety of the workers. Nothing should measure above workplace health and safety. Not sales quotas, not deadlines, not salary bonuses, and certainly not potential promotions - but do you see the problem?
Properly preventing accidents, particularly those attributable to human error, is a difficult, time-consuming, and sometimes expensive task that many employees and employers alike are resistant to. When human error enters the equation, people often blame, well, humans, for the errors, and the sentiment of "you shouldn't have made the mistake in the first place" can prevail. But there are several important principles to consider:
- People are fallible, and even the best people make mistakes.
- Error-likely situations and conditions are predictable, manageable, and preventable.
- Individual performance is influenced by organizational processes and values.
- People achieve high levels of performance largely because of the encouragement and reinforcement received from leaders, peers, and subordinates.
- Incidents can be avoided through an understanding of the reasons mistakes occur and application of the lessons learned from past incidents.
These 5 points are taken from NFPA 70E 2018, Informative Annex Q entitled Human Performance and Workplace Electrical Safety, and they are vitally important points for businesses to keep in mind. Any safety program which does not account for occasional errors by workers is failing in its duty of care. You need to be able to communicate the inherent value of a safety program that seeks to eliminate the most likely areas and/or tasks that are prone to human error to every member of staff, on every ring of the chain.
Also important is how the brain actually processes information. To quote the Annex again, the stages of information processing are:
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Attention - where and to what we intentionally or unintentionally direct our concentration
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Sensing - Sensory inputs (hearing, seeing, touching, smelling, etc.) receive and transfer information
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Encoding, storage, thinking - Incoming information is encoded and stored for later use in decision making (i.e., what to do with information). This stage of information processing involves interaction between the working memory and long-term memory (capabilities, knowledge, past experiences, opinions, and perspectives).
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Retrieval, acting - Taking physical human action based on the synthesis of attention, sensation, encoded information, thinking, and decision-making. In a workplace environment this would include changing the state of a component using controls, tools, and computers, including verbal statements to inform or direct others.
Although this concept is fairly self-explanatory, there's still room for misinterpretation, so here's a real-world example:
A construction worker is cutting a benchtop, with all their proper protective clothing and respiratory protection, along with hearing protection. Their attention is solely on their task, as it should be... but they see something out of the corner of their eye. Whether or not it's real or not - be it a shadow, a tree branch, a snake, or one of their coworkers - they think they see it, and so their attention is drawn away from their task. As a result of their momentary distraction, the stone cutter goes off-track, and disaster strikes.
While this is attributable to human error - they shouldn't have gotten distracted in the middle of something so dangerous, or they should have held the cutter still while they looked, or what have you - they had no control over their reaction, and it was just an unfortunate accident.
This example is very simple, of course, and most real-world examples are much more muddy and involve much more than just attention, but the point is made - 'human error' is not always cut and dry. People make mistakes - a safety program needs to work to minimise both the frequency and severity of them.
Finally, there are three different 'human performance modes' - the ways in which somebody acts while performing a task. These are, in short:
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The rule-based human performance mode is based on previous experience and training, often by formal job skills or operational training. The most desirable of the performance modes, it still has error potential. As the primary focus of this mode is logic—if X, then Y—a misinterpretation of the situation can result in applying the wrong response or procedure.
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The second human performance mode is knowledge-based performance. When workers comes across an unfamiliar situation, they must apply what they know about (allegedly) similar situations or supplement that existing knowledge with research. The inherent problem is a lack of complete knowledge, and an incorrect decision when they’re require to “think on their feet.”
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Finally, the third human performance mode is skill-based performance. This means the worker has performed the task repeatedly and is intimately familiar with it. You might think this is a good thing. But, not necessarily. As the old saying goes, “Familiarity breeds contempt.”
The error potential presents itself when changes to the work environment or actual task, the individual’s capabilities (impairment via health or related issues), and that old adversary, human nature, materialize.
We've all done something as simple as driving down the wrong road after moving house, or putting the milk back in the fridge before we actually poured ourselves a drink. Skill-based performance especially leans into those mistakes and catastrophises them - instead of putting the milk in the fridge, we attach an electrical wire before the power's turned off and get electrocuted. Simple, easy mistakes that anybody could make, but they can lead to people getting hurt or killed.
What can you do about that?
Unfortunately, human error can never be removed entirely from the equation. Even an entirely mechanical system is prone to error if the person who designed it didn't account for something, or if it breaks down due to overuse. However, while we can't outright prevent it, we can minimise it. A computer-based system can lock things unless certain parameters are met (i.e you can't get into the power box unless the electricity is off), or procedures can be tweaked so that a single task takes multiple people to 'sign off' that it's complete and correct.
If an incident was investigated and it was found that a coworker unexpectedly opening the door to the stone-cutting room caused an accident, then the door can be signposted in future if cutting work is being performed, to prevent future distractions.
For further information, view the MSA blog on this topic here
