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HEALTH AND SAFETY AT WORK MAGAZINE

CAPTURING THE HUMAN FACTOR

By Mike Everley

"We seem to have passed the era where the need

was for further engineering safeguards in particularly

hazardous industries. What we now need is to

capture the human factor"

John Rimington - ex Director General HSE

Background

Safety, in recent years, has focused on physical and engineering controls and upon safe workingprocedures. Its hardly surprising therefore that, after designing safe equipment and devising safesystems of work, the focus should now be turned onto that other variable- the human being. Greaterimprovement in safety performances may rest upon a greater understanding of employees and their

attitudes and behaviour in the workplace.

Understanding employee behaviour is also a central requirement in a self-regulatory system, where thecontrols and influences are more likely to come from within the organisation than from external bodiessuch as the Health and Safety Executive. Although external bodies such as insurance companies canexert considerable financial pressure on self-regulatory organisations to develop a human factorsapproach to health and safety. Such an approach can include the screening-out of employees whopresent an above-average risk. Furthermore, there has been a perceivable shift towards greater individualresponsibility for the health and safety of ourselves and others.

Safety Practitioners have often relied upon the safe place safe person strategy to direct their thinkingand such a strategy often underpins both risk assessment techniques and accident causation models as

the following diagram illustrates.

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The term "human factors" is often used to cover a range of issues. These include the perceptual, mentaland physical capabilities of people and the interactions of individuals with their jobs and working

environments, the influence of equipment and systems design on human performance and, above all, theorganisational characteristics which influence safety-related behaviour at work. This safety-relatedbehaviour forms the base of the accident triangle (whichever variant of the triangle is used).

Put simply, there is a ratio between the near misses at the base of the accident triangle and the majorinjuries at the top (the exact ratio varying according to the variant of the technique adopted). It is oftenonly luck which determines which incident will be a near miss and which will be more serious.However, it is the behaviour patterns of the individuals involved which give rise to both the near misses




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and the more serious accidents. Therefore, near misses are also preventative opportunities for the SafetyPractitioner as they indicated which behaviour patterns need to be changed before luck runs out and aserious accident occurs.

However, it is important not to jump to the conclusion that incorrect behaviour patterns on behalf ofindividual employees equates directly with fault. Often the behaviour patterns are a result oforganisational failures or pressures to which individual employees are merely responding. Organisations

wishing to correct inappropriate behaviour patterns need to consider every rule and procedures, in alloperational and emergency situations, and to replace those which cannot be followed with new rules andprocedures that can be followed. Employees will then need to be trained in the new rules and proceduresand monitoring systems will need to be introduced in order to ensure that they are, in fact, beingfollowed. This approach requires a fairly heavy resource commitment on behalf of the organisation.

It is within this context that the Health and Safety Executives publication Reducing Error andInfluencing Behaviour(HSG48) needs to be considered.

HSG48

Reducing Error and Influencing Behaviour is in fact a substantial revision of the previous publicationHuman Factors in Industrial Safety and it is good to note that the Health and Safety Executive havenoted the perceptual failings with regard to the previous publication notably the fact that the termindustriallimited the scope of the audience despite the fact that human factors apply to all workplaces(this misperception was reinforced by the use of a heavy industrial scene on the front cover and theselection of examples mainly relating to heavy industry). The new publication is clearly directed at allworkplaces and all work activities (as the front cover, title and selected examples clearly reinforce).

According to Reducing Error and Influencing Behaviour: "Human factors refer to environmental,organisational and job factors, and human and individual characteristics which influence behaviour atwork in a way which can affect health and safety". In other words the three crucial elements of job,individual and organisation need to be carefully considered.

Element Detail

Job Factors Requires tasks to be designed in a waythat takes into account ergonomicprinciples and recognises strengths andlimitations in human performance.Matching the job to the person requiresconsideration of both a physical and amental match. It is the mismatch

between job requirements and individualcapabilities that provides the opportunityfor human error. Hence the need tomatch the employees capabilities to thetask they are being asked to perform asrequired by the Management of Healthand Safety at Work Regulations 1999.

Individual Factors Individual characteristics such as




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In order to begin to develop a fully-fledged human factors strategy, the above factors should beconsidered during risk assessment, accident investigation, design and procurement as well as in day-to-day operations.

The key objective of the publication is to move away from the mistaken notion that accidents andincidents are the result of human error by the worker in the front line. "Attributing incidents to humanerror has often been seen as a sufficient explanation in itself and something which is beyond the controlof managers. This view is no longer acceptable to society as a whole. Organisations must recognise thatthey need to consider human factors as a distinct element which must be recognised, assessed andmanaged effectively in order to control risks".

With regard to the three main factors, the following causes are often related to human failures inaccidents:

Job Factors

Illogical design of equipment, instruments.

Constant disturbances and interruptions.

Missing or unclear instructions.

Poorly maintained equipment.

High workload.

Noisy and unpleasant working conditions.

Individual Factors

Low skill and competence levels.

personal attitudes, skills, habits andpersonalities can be strengths orweaknesses depending upon taskdemands. Certain individualcharacteristics, such as personality, arefixed, whereas other characteristics, such

as skills and attitudes can be modified orenhanced.

Organisational Factors Organisational factors have the greatestinfluence upon individual and groupbehaviour. The organisational culture,for example, needs to promote employeeinvolvement and commitment at alllevels and emphasis that deviation fromestablished health and safety standards isnot acceptable.




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Tired staff.

Bored or disheartened staff.

Individual medical problems.

Organisational Factors

Poor work planning, leading to high work pressure.

Lack of safety systems and barriers.

Inadequate responses to previous incidents.

Management based upon one-way communications.

Deficient co-ordination and responsibilities.

Poor management of health and safety.

Poor health and safety culture.

If the above are common causes of human failures, the failures themselves can be categorised intovarious types involving errors and violations. The following diagram illustrates this point:




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The above model operates with the notion that all human failures can be categorises as either humanerror or violations depending on whether or not intention was involved with the failure. A human errorbeing an action or decision which was not intended, but which involved a deviation from an accepted




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standard and which led to an undesirable outcome. Errors can be sub-divided into slips, lapses andmistakes.

Errors are more likely to occur where there are: Work environment stressors, Extreme task demands,Social and organisational stressors, Individual stressors, Equipment stressors. Risk assessments shouldtherefore identify where such factors are present and assess the likelihood of errors taking place andtheir consequences. Error control and reduction should take into account the need: To address theconditions and to reduce the stressors, To design plant and equipment in order to either prevent slips orlapses occurring or to increase the chances of detecting and correcting such errors, To ensure thatarrangements for training are effective, To design jobs to avoid the need for tasks which involvecomplex decisions, diagnoses or calculations, To provide proper supervision, To check that job aidssuch as procedures are clear, concise, available, up-to-date and accepted, To monitor that the measurestaken to reduce error are effective.

Whereas, a violation is a deliberate deviation from a rule or procedure. Most violations are motivated bya desire to carry out the job despite prevailing constraints and very rarely are they motivated by wilfulacts of sabotage or vandalism. Violations can be sub-divided into routine, situational and exceptional.

Slip Lapse Mistakes

Failures in carrying out

the actions of a task. Inother words "actions notas planned". These mightinclude: Performing anaction too soon or toolate, Omitting a step orseries of steps from a task,Carrying out an actionwith too little or too muchstrength, Performing theaction in the wrongdirection, Doing the rightthing but with regard tothe wrong object,Carrying out the wrongcheck but on the rightobject.

Forgetting to carry out an

action, to lose our place ina task or to forget whatwe had intended to do.Often linked tointerruptions anddistractions. A simplechecklist to follow canhelp to reduce thelikelihood of lapsesoccurring.

Where we do the wrong

thing believing it to beright. The failure involvesour mental processeswhich control how weplan, assess information,make intentions and judgeconsequences. Rule-BasedMistakes occur when ourbehaviour is based uponremembered rules orprocedures. Knowledge-Based Mistakes are oftenrelated to incompleteinformation beingavailable.

Routine Situational Exceptional

Breaking rules or procedureshas become a normal way ofworking within the work groupdue to: The desire to cutcorners, The perception that therules are too restrictive, Thebelief that the rules no longer

Breaking the rules isdue to pressuresfrom the job, suchas: Time pressure,Insufficient staff forthe workload, Theright equipment not

These rarely happen and onlywhen something has gone wrong.To solve a problem employeesbelieve that a rule has to bebroken. It is falsely believed thatthe benefits outweigh the risks.Means of reducing such violations




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Developing a Strategy

HSG48 provides a powerful model showing the type of human errors and violations that can bepredicted from consideration of organisational, job and individual factors. Such a model can be usedboth in risk assessments and accident investigations in order to suggest the control measures required toprevent either an occurrence or a re-occurrence. The HSE Contract Research Report 175/1998Individual differences in accident liability: A review provides an integrated model of accident liabilitywhich can be utilised in relation to the model provided by HSG48.

apply, Lack of enforcement ofthe rules, New workers notrealising that routine violationsare taking place. Means ofreducing such violations caninclude: Routine monitoring,

Removal of unnecessary rules,Ensuring rules are relevant andpractical, Explaining thereasons for the rules, Improveddesign to reduce the likelihoodof cutting corners, Involvementof the workforce in drawing-upthe rules.

being available,Extreme weatherconditions. Riskassessments shouldhelp identify thepotential for such

violations as willgood two-waycommunications.

could include: Training fordealing with abnormal situations,Risk assessments to take intoaccount such violations,Reduction of time pressures onstaff to act quickly in novel

situations.




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According to the Contract Research Report: " In terms of personality, the evidence presented in thisreview suggests that extroversion and neuroticism are linked to increased accident vulnerability, butdoes not suggest why this should be so. It is plausible that while neuroticism may be associated with




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accidents via an increased vulnerability to stress, extroversion may increase an individuals willingnessto take risks. The model of accident liability attempts to integrate the findings of research into individualdifferences in accident liability with more recent research into the various forms of human failure andtheir role in accident causation. The model offered also attempts to link psychological, organisationaland behavioural factors together in the accident-producing nexus".

Job analysis is a useful technique allowing for the identification of important behavioural and

performance qualities and for the matching of individuals to jobs. However, it should always beremembered that the personality characteristics that give rise to safe performance in one situation mayprove detrimental in another situation. For example; a rigid approach to rules and procedures may berequired in most instances, but a more flexible approach be required in an emergency situation. Suchfactors need to be considered when risk assessments are performed in relation to normal operations andemergencies.

Where the safety culture is clear and positive, group pressure can even influence an unstable extrovertnot to take risks. However; where the culture is ambivalent, and linked to performance targets anddeadlines, the message may become that short-cuts are acceptable in order to achieve targets.

HSG48 provides the following useful checklist of questions which organisations can adopt whendeveloping a strategy based upon the control of organisational, job and individual factors which can leadto human failings:

The Job

Have you:

Identified and analysed critical tasks?

Evaluated the employees decision-making needs?

Evaluated the optimum balance between human and automatic systems?

Applied ergonomic principles to the design of equipment displays includingdisplays of plant and process information, control devices and panel layouts?

Thought about the design and presentation of procedures and instructions?

Considered available guidance for the design and control of the workingenvironment including the workspace, access for maintenance, lighting, noiseand thermal conditions?

Provided the correct tools and equipment?

Scheduled work patterns and shift organisation to minimise impact on healthand safety?

Considered how to achieve efficient communications and shift handover?

The Individual




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Have you:

Drawn up job specifications looking at age, physique, skill, qualifications,experience, aptitude, knowledge, intelligence and personality?

Matched skills and aptitudes to job requirements?

Set up personnel selection policies and procedures to select appropriateindividuals?

Implemented an effective training system?

Considered the needs of special groups of employees?

Set up monitoring of personal performance on safety for safety critical staff?

Provided fitness for work and health surveillance where this is needed?

Provided counselling and support for ill health or stress?

The Organisation

Do you have:

An effective health and safety management system?

A positive safety climate and culture?

Arrangements for the setting and monitoring of standards?

Adequate supervision?

Effective incident reporting and analysis?

Learning from experience?

Clearly visible health and safety leadership?

Suitable team structures?

Efficient communication systems and practices?

Adequate staffing levels?

Suitable work patterns?

References

Reducing Error and Influencing Behaviour. HSG48. HSE Books. 11.50.




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Individual Differences in Accident Liability: A Review. Contract Research Report 175/1998.University of Manchester Department of Psychology. HSE Books. 20.00.

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