Exploring the link between Human Error and Risk Management
Have you ever…
Gone into the kitchen, turned the kettle on and come back a few minutes later to put the kettle on again? Have you ever locked the door, got into your car and then got back out to check the door is locked? Have you ever got to the car park at work and wondered how did I get here? If you have, you are not alone. Every day, we all experience some form of “human error”.
Human error is the go to term for the media to explain why an accident has occurred. You may have heard the term on the news when journalists report on large-scale accidents such as the Kegworth Air Disaster, the sinking of the Zeebrugge ferry and more recently the 2012 Costa Concordia accident where a cruise ship ran aground. In these types of events before a proper investigation takes place, causation is described as “pilot error” or “driver error”.
Human errors occur when your brain fails to processes a task or series of tasks. For this reason, human error is an intriguing subject for risk management as it helps us understand why people do what they do and gives us some insight into the prevention of accidents in the workplace.
So, where did the science of human error start?
In 1976, a young PhD Student called James Reason got up from his desk in his student flat in Manchester and went to make himself a cup of tea. When he sat back at his desk, he found he had made himself a cup of hot water and milk. James thought to himself “That’s interesting, I wonder why that happened!” and the study of human error began.
In 1990, Reason defined human error as “the generic term to encompass all those occasions in which a planned sequence of mental and physical activities fails to achieve its intended outcome, and when these failures cannot be attributed to the intention of some chance agency” 1
The definition is great. However, does that really explain why you forgot to put a teabag into your mug?
After years of research, Reason has categorised human errors into four core areas – Slip, Lapse, Mistake or Violation.
Slip – A slip is a skill-based error due to inattention or over-attention where frequently performed tasks go wrong, like arriving in the carpark at work but not being able to remember the journey.
Lapse – A lapse is a skill-based error due to memory failure where you forget to perform the required actions of a task such as making a cup of tea but forgetting your teabag.
Mistake – Rule-based error where you apply or misapply the rules relating to a task. These types of error occur when you have training to use machinery by another person and you pick up their incorrect way of working or bad habits.
Violation – Violations are the most interesting of all aspects of human error and can be broken down further into the following types:
- Routine – “We’ve always done it this way; this is the way we do it”
- Situational – Firefighters running into a burning building, they know it is wrong but they do it because they have to pull someone out of the building
- Optimising – It was the best way to complete that task at that time
- Exceptional – A one off way of working to complete the task regardless of consequences
- Sabotage – Malicious and deliberately detrimental to the organisation 2
This is where it gets interesting for risk management.
When we investigate client accidents, we are able to determine which area of human error the accident derived from and how that relates to the other root causes of the accident. This ultimately determines what actions the client should take to prevent reoccurrence of that accident and reduce their claims.
The aim of any good investigation is not to apportion blame but to prevent reoccurrence, unless we find an exceptional or sabotage violation. In these instances, we need to review the accident from an Employment Law perspective as well as Health and Safety to assist with the determination of disciplinary action.
Human error itself is only part of the causation of accidents. Disasters happen because a whole series of mistakes, mischances and misjudgements come together in a deadly combination. Take the Challenger Space Shuttle disaster in 1986, where the shuttle exploded 76 seconds into the flight due to a catastrophic O ring failure 3 – in addition to an exceptional violation where concerns about the o ring were raised and refuted due to group think; there were a whole series of other pressures that came together to cause the disaster. These include pressure over launch delays, budget pressures forcing the launch, conflict in communications prior to take off and poor decision making.
Human error is inevitable and we must learn from these occurrences by being vigilant, having the confidence to report concerns in order to mitigate or minimise the effect before an accident happens. If you accept that human errors will occur in your business, you can address what you can and manage the rest with support from our risk management team.