Whilst writing a blog article on the cost of warehouse accidents, I was looking at a list of the most costly accidents to date throughout the world (the blog article can be found here). What I realised was that 50% of those major accidents were caused by human error. The rest were a mixture of IT failures / manufacturing faults / communication errors etc. Human error has the potential to have a very devastating consequence simply because we cannot predict them, to a certain point. Most workplaces need people, and some employees have enormous responsibilities. Could we eliminate human error?
When is good performance good enough? At what point do we rest on our laurels and relax our defences? As you would imagine, never. In USA in 2012, it was recorded that 13 people go to work each day who never return home - this highlights the importance of being 'on guard' all the time.
When we start to think that there is not much room for improvement, we should remind ourselves of the following:
If we were 99.99 percent accurate, we would still experience (statistics based on USA data):
- 500 incorrect surgical operations each week
- 50 newborn babies dropped at birth by doctors everyday
- 22,000 checks deducted from the wrong bank account each hour
- 32,000 missed heartbeats per person, per year
- 114,500 mismatched pairs of shoes shipped each year
- 200,000 documents lost by the IRS this year.
First we need to understand what a human error is. Human error is defined in many ways. One definition that I like is "any action, performed by a person, which exceeds a system's tolerance." Human error is an error and not an intentional act for harm. Sabotage is not considered a human error, unless the result of the actual intentions is different than was expected. So stating that a human error has occurred does not necessarily mean that is the "human's" fault.
We as humans don't operate in a vacuum. Behaviors are influenced by external as well as internal variables. In manufacturing environments, these variables can be divided into six major categories: procedures, human factors, training, supervision, communication, and the individual itself.
Individuals are certainly responsible for their actions. But before we determine that internal factors like attitude or attention are responsible for the mistake, we as organizations are responsible for eliminating the possibilities of external factor influencing human behavior. Individual performance in manufacturing is proven to be responsible for less than 5 percent of deviations. For example, if an employee fails to notice defects because of lack of appropriate vision, shouldn't the organization make sure visual exams are performed regularly? Even in this example, we can see that a "fit for duty" system is weak.
What Can Be Done?
The most effective way to control human error is to implement good systems. Systems take care of human factors (any aspect of the workplace or job implementation that makes it more likely for the worker to make an error) as well as external factors. We can start by:
- Providing clear, accurate procedures, instructions, and other job aids (consider Five Checklists to Avoid Forklift Related Accidents).
- Implementing good, human, factors engineered for control systems, processes, equipment and work environments (consider the self-relocating curtain of a high speed rapid door, engineered to work WITH speedy forklift drivers)
- Provide relevant training and practice
- Provide appropriate supervision
- Assure good communications
- Make sure the personnel have all the capabilities needed to succeed in the assigned task.
While errors may be simple memory or attentional failures, they can be exacerbated by:
Routinisation – the mark of a craftsman whereby the individual becomes so expert at exercising a particular skill, that he/she no longer consciously thinks about, it allowing the mind to wander and the unexpected to happen – drivers who regularly travel the same route to the station each day suffer from this – ‘am I here already?’
Normalisation – the process of forgetting to be afraid – interestingly most accidents on mountains happen on the way down from the summit – only a relatively small number happen on the way up.
Intrinsic hazard – no matter how well you defend yourself the dangers ‘out there’ never go away – move outside your protective ‘bubble’ and something or someone will get you!
Creeping entropy – systems, policies and procedures grow old or fail to adjust to changing external factors thus increasing the propensity for accidents to happen.
Murphy’s Law – if it can happen it will happen, but there is also Schultz’ Law. Mr Schultz merely said that Murphy was an optimist!
We have already spoken about breaking the ‘rules’ but what precisely are they? Basically they are procedures written to shape people’s behaviour so as to minimise accidents. They are, if you like, standards designed to form part of the system defences against accidents. Defences are installed to protect the individual, the asset or the natural environment (all ‘objects of harm’) against uncontrolled hazards and generally appear in two forms:
‘Hard’ defences, provided by fail-safe designs, engineered safety features and mechanical barriers.
‘Soft’ defences provided by procedures, rules, regulations, specific safety instructions and training.
Implementing 'hard' defences may be: better lighting around potentially dangerous machinery, installing barriers / bollards around areas which are dangerous to unsuspecting pedestrians, or even installing bollards and guardrails as a guide to make sure employees don't find themselves in the 'line of fire' such as in the path of moving machinery and vehicles. By preventing people from being where they arent meant to be, could save you a whole headache of other Health and Safety issues.
Smart technology has also made it possible to reduce human error at work by mechanically making decisions for you, such door sensors. Large Rapid Doors in warehouses can be controlled by sensors which could help to:
- Warn you of oncoming traffic
- Automatically close the door after you have entered / exited to prevent staff leaving doors open to outdoor elements / pests / thieves
- Sense when a person/vehicle is below the door and therefore remain open, avoiding potentially dangerous accidents by doors closing onto people and machinery.
At the end of the day, the facts are:
- Good people make honest mistakes
- A fast-paced, ever-changing world sometimes outsmarts us
- We can never work error free
- If we lower human error, we will lower failure rates
- Systems are not basically safe
- People design safety into systems, they do not come prepackaged that way
- Most people come to work prepared and have the relevant knowledge to be successful
And a few key notes to take away:
- New hires are more prone to knowledge-based errors
- As we gain more years of experience we are more prone to become complacent with our jobs
- Highly experienced employees typically are less prone to skill-based errors however, they will become complacent and overconfident and cause such errors
- When a major skill-based error occurs and results in an undesirable outcome, then the system tends to "reset" back to zero
*All content provided on this blog is for informational purposes only. The owner of this blog makes no representations as to the accuracy or completeness of any information on this site or found by following any link on this site.
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