Human failure in the workplace – CPD

Dr Julian Hought explains why businesses should combine a ‘lean’ approach to human factors with legislative compliance to improve safety and efficiency.

We’re all familiar with the phrase ‘to err is human’, which is why many companies take great pains to guard against human failure in the workplace. Even so, human behaviour is still a major contributory factor in many industrial accidents. But given that humans are responsible for the design, build, manufacture, operation and maintenance of manufacturing and processing plants this really isn’t so surprising.

The fact that human behaviour can be classified, predicted and controlled is not new. ‘Human factors’ has been an HSE hot topic for many years and, for most companies, it is an essential element in the risk-assessment process. Actual sabotage is extremely rare, so organisations need to take account of the other four main types of human failure: slips, lapses, mistakes and violations.

Slips happen when an action that is performed frequently goes wrong, i.e. the wrong button is pressed accidentally. Lapses, on the other hand, can occur when somebody performing a task is interrupted partway through, then cannot remember where they were in the sequence. As a result, a couple of safety-critical steps are omitted, which can trigger a series of events leading to an accident, or compromise the safety or quality of a product. This type of error has particular relevance not only to operations but also to maintenance activities.

Human failures classified as ‘mistakes’ are one of the most dangerous types of error. In this case, it is often lack of training, or a misunderstanding that cause an individual to do the wrong thing, while genuinely believing their actions to be right. This can lead to miscalculations, or incorrect diagnoses of situations; a good example is the application of familiar procedures to unfamiliar situations.

Violations are also deliberate breaches of rules and regulations, but the reasons behind them are generally well-intentioned. Often, a member of staff will ignore procedures or take shortcuts in a desire to complete a job in a timely manner, despite opposing circumstances. This is a particular concern in the current climate, when companies are trying to keep their heads above water and deliver more with less resource, using plant and equipment that is being pushed beyond their natural retirement date.

‘Routine violations’ often become accepted as ‘the norm’ within a staff peer/ work group. This is a danger in itself, as it then becomes acquired knowledge passed from worker to worker. ‘Exceptional violations’, on the other hand, only occur when something goes wrong in unpredicted circumstances – for example, in an emergency situation. ‘Situational violations’ occur as a result of factors dictated by the worker’s immediate workspace, or environment (physical or organisational).

Other factors that can heighten the risk of human failure include distractions, tiredness, resources, work patterns, work overload, communication, leadership and the culture of the workplace. It is virtually impossible to change somebody’s personality – as the saying goes, “a leopard cannot change its spots” – but other characteristics, such as skills, attitudes and competence can be changed, or enhanced.

Combine and win

While many companies are already involved in identifying and controlling, as far as reasonably practicable, the risks human failure pose, and are taking steps to manage the solutions effectively, often this is done purely from a regulatory perspective. Complying with safety legislation is obviously important but if businesses are to remain competitive in an uncertain climate they might want to consider a different approach, which can minimise risk, satisfy legislation and, at the same time, improve productivity and efficiency.

Combining regulatory compliance with ‘lean’1 and ‘Six Sigma’ principles2 can be very effective in realising significant improvements in the safety of operations. Whereas traditional risk assessment relies on data, the lean approach combines data with a more personal approach, often gathering together a cross-functional team to get to the root causes of why a process or action is not functioning as it should.

The benefits of this approach are two-fold. Firstly, you are engaging with employees who are involved with the day-to-day operation of your facility. This gives you insight and anecdotal information that may not have been logged as data. Secondly, you are giving employees the opportunity to explain why they perform tasks in a particular way and offer their own suggestions for improvement. Asking those at the coal face what they do and why it goes wrong can be far more effective than questioning senior management.

Lean principles always try to achieve a ‘continuous flow’ of operations through the elimination of waste in all its forms, while to attain Six Sigma status a business must have an incident rate of no more than 0.34 per 100,000 opportunities. The results of this type of risk assessment focus on safety-critical elements and allow a number of error-proofing measures to be put into place, which ensure safety, reduce the chance of inaccuracies and, as a result, improve productivity.

Keep it safe and simple

We may not be conscious of the fact, but error-proofing is a part of our everyday lives. We use myriad products that have been designed to ensure we don’t make the wrong decision, or do something that will harm ourselves, our property, or the wider environment. For example, medicine bottles have tamper-proof caps to prevent young children from accessing their contents; a microwave will not begin cooking unless the door is closed; three-pin plugs can only be inserted into a socket a certain way; unleaded petrol has a green nozzle whereas diesel is black, etc.

In certain types of businesses, the case for error-proofing to combat human failure is particularly strong. In the high-hazard industries a momentary lapse of concentration during a regularly performed task, a miscalculation in calibration, insufficient training, or the wrong decision leading to faulty design, can give rise to potentially disastrous consequences, so it is in senior management’s interests to take an active role.

The most effective measure is to remove the ability to make the error in the first place. Examples of useful error-proofing devices include guide pins to ensure correct assembly; limit switches to sense the presence or absence of a part; mistake-proofing jigs to detect defects immediately upstream; counters to verify the correct number of parts or steps; and checklists that remind staff to perform certain actions. It is not always easy to completely eliminate the possibility of making a mistake, so work instructions, cue cards and warning notices should also be employed.

All of the above seek not only to eliminate or mitigate the possibility of accidents but also, if employed correctly, they can help improve communication, speed up operations, substantially reduce rework, cut waste and hence ultimately improve the company’s bottom line.

‘Value stream’ mapping exercises, which record every step of every activity, are also extremely useful in the error-proofing process. They not only identify error potential but also seek to simplify procedures by reducing the number of steps involved. Fewer steps mean less human interaction, less opportunity for error, reduced potential risk, and a more streamlined operation.

While large batch sizes generally mean greater economy, there are some instances where reducing the batch size can improve accuracy and efficiency. This is especially beneficial in such work environments as hospital laboratories, as it means that data and samples can be co-processed, leading to improved quality, fewer mistakes, and shorter lead times.

Another particularly effective ‘lean’ principle that can be applied to human-factors risk assessments is ‘5S’ workplace organisation.3 Workplace organisation can not only facilitate efficiency it can also help avert serious accidents. It involves ensuring that the right tools for the job are always available (a place for everything and everything in its place – shadows and colour-coding are useful devices) and then putting procedures in place to ensure that corners are not cut.

Visual management systems make for a productive environment and reduce the opportunities for errors. Visual controls enable anyone in the workplace to see in a clear, simple and visual form the status of the process – for example, whether or not the equipment is running correctly, which product or batch is being made, what stage the production is at, whether conditions are normal or abnormal, when new material needs to be re-ordered, plus any corrective actions that need to be taken.

Communication, communication, communication

The exchange of information is often as critical to safety as the various physical measures put in place. A prime example of this is when a shift handover occurs. Verbal information can easily be inaccurate, misunderstood, or omitted. If log books and handover reports are used to catalogue what has occurred during a shift and record any anomalies – for instance, if maintenance has been undertaken – this can go a long way to speeding up procedures and improving safety. It also assists in the design of management change programmes, since it can be combined with equipment data to give a fuller picture.

Variation in any operation is almost certain to cause problems – it decreases throughput, reduces product quality, can hinder problem-solving and hide improvement opportunities, and, ultimately, increases cost. In order to reduce accidents or safety violations you should be looking to standardise processes wherever possible and ensure that relevant staff understand why particular processes are in place and the consequences in safety terms of not adhering to them. Appropriate training is the key here, but also the development and implementation of Standard Operating Procedures (SOP).

Experience has shown that involving operators in the writing of SOPs can reap huge rewards. They are forced to think about the best way of performing tasks within the allocated timeframes and because they are involved in the development process, you can be certain that the SOPs are understood. Giving employees ownership often results in the added bonus of increased efficiency. The more standardised and streamlined a process becomes, the less the margin for human error and the more efficient and productive the operation.

References
1    Lean principles essentially focus on identifying and eliminating waste in production/work processes, thus improving efficiency and reducing costs, i.e preserving value with less work
2    Developed at Motorola in the 1980s, Six Sigma is a quality initiative that uses data and statistical analysis to measure business processes and their outcomes. The cornerstone of the Six Sigma methodology is the concept of a defect – defined as a failure to deliver what the customer wants – and the central principle is that by measuring the defects a process produces, you can systematically identify and remove sources of error with the aim of reaching the ideal state of no defects at all
3    5S is the name of a workplace organisation methodology that uses a list of five Japanese words that describe how to organise a work space for efficiency and effectiveness by identifying and storing the items used, maintaining the area and items, and sustaining the new order. The decision-making process usually comes from a dialogue about standardisation, which builds a clear understanding among employees of how work should be done. It also instils ownership of the process in each employee

Dr Julian Hought is managing director of HFL Risk Services.

Continuing professional development is the process by which OSH practitioners maintain, develop and improve their skills and knowledge. IOSH CPD is very flexible in its approach to the ways in which CPD can be accrued, and one way is by reflecting on what you have learnt from the information you receive in your professional magazine. By answering the questions below, practitioners can award themselves credits. One, two or three credits can be awarded, depending on what has been learnt – exactly how many you award yourself is up to you, once you have reflected and taken part in the quiz.

QUESTIONS:
Note: there is more than one correct answer to some of the questions

1    Standard Operating Procedures (SOPs) help staff understand:
a.    That variety in operations can cause problems
b.    How it increases cost
c.    Processes
d.    Their terms and conditions

2    There are four main types of human failure:
a.    Indifference, sabotage, destruction, malice
b.    Slips, lapses, mistakes, violations
c.    Violations, sabotage, lapses, indifference
d.    Not turning up to work

3    The most dangerous type of error is:
a.    Indifference
b.    Mistakes
c.    Wilful interference
d.    Taking shortcuts

4    Violations can be:
a.    Deliberate breaches of rules and regulations
b.    Often well-intentioned
c.    A result of taking a shortcut
d.    Not turning up to work

5    Violations can also be:
a.    A result of exceptional circumstances
b.    A result of following all the rules
c.    Sometimes accepted as ‘the norm’
d.    Unpredictable

6    Human failure can be caused by:
a.    Work overload
b.    Correct resources
c.    Poor communication
d.    Good leadership

7    There is a number of ways to control the risks posed by human failure, including:
a.    Complying with safety legislation
b.    Assessing risks posed by the work and utilised control measures
c.    Using the Six Sigma principles
d.    Moving to more mechanised processes with less human interaction

8    Workplaces need to use error-proofing to combat human failure.  Examples of this from everyday life are:
a.    Three-pin plugs
b.    Colour-coded petrol nozzles
c.    Machines that continue to run when they are left to idle
d.    Gadgets that work when closed

9    Value stream exercises record:
a.    Opportunities for error
b.    Every step of an activity
c.    Accidents
d.    Failures

10    Workplace organisation facilitates:
a.    Corrective actions that need to be taken
b.    Efficiency
c.    Colour-coding to make the workplace attractive
d.    The right tools for the job being available

Answers:

1.    a, c
2.    b
3.    b, d
4.    a, b, c
5.    a, c, d
6.    a, c
7.    a, b, c
8.    a, b, d
9.    a, b, d
10.    a, b, d

The Safety Conversation Podcast: Listen now!

The Safety Conversation with SHP (previously the Safety and Health Podcast) aims to bring you the latest news, insights and legislation updates in the form of interviews, discussions and panel debates from leading figures within the profession.

Find us on Apple Podcasts, Spotify and Google Podcasts, subscribe and join the conversation today!

Listen here!