Incident investigations identify human failure as the key cause of almost all accidents, creating the impression that people cause incidents. However, human error is not simply a feature of individual failure, but is caused by workplace factors, equipment, and task design, among others. Mistakes are typically due to conditions and systems that make work difficult.
This is the third guiding principle of the eight OCIMF principals on human factors, highlighting the importance of not putting the blame on a specific person for an incident but try to see why the system allowed it to happen. A poorly designed activity might be prone to a combination of errors and more than one solution may be necessary. Incident investigations should seek to identify why individuals have failed rather than stopping at ‘operator error’. In any case, human failure is normal, predictable and, most importantly, manageable.
7 key items for efficient operations
#1 Management systems
Documentation control, investigation management, risk management and project management are vital
#2 Procedures
It is important all procedures to be accurate, human-engineered and enforceable
#3 Human factors engineering
Work areas need to be designed with human factors and human capabilities in mind
#4 Training
On the job training and skills development are necessary for critical tasks and activities
#5 Supervision
Pre-job briefs, walkthroughs, presence and instructions to workers are necessary
#6 Communication
Provide feedback on what needs to be achieved and the proper way to do it
#7 Assess Individual Performance
Evaluate all conditions that could potentially create cognitive overload i.e. fitness for duty, fatigue management, complexity and task design
The “human failure” on almost all incidents,is well identified.
Why and how incidents happen,are well analysed by Todd Conklin PHD in his “the 5 principles of human performance” book,that we all must read.
The problem is how one can measure the causes and the impovements.