"We seem to have passed the era where the need

Safety, in recent years, has focused on physical and engineering controls and upon safe working procedures. It’s hardly surprising therefore that, after designing safe equipment and devising safe systems of work, the focus should now be turned onto that other variable- the human being. Greater improvement 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 the controls and influences are more likely to come from within the organisation than from external bodies such as the Health and Safety Executive. Although external bodies such as insurance companies can exert considerable financial pressure on self-regulatory organisations to develop a human factors approach to health and safety. Such an approach can include the screening-out of employees who present an above-average risk. Furthermore, there has been a perceivable shift towards greater individual responsibility for the health and safety of ourselves and others.

Safety Practitioners have often relied upon the safe place – safe person strategy to direct their thinking and such a strategy often underpins both risk assessment techniques and accident causation models as the following diagram illustrates.

The term "human factors" is often used to cover a range of issues. These include the perceptual, mental and 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, the organisational characteristics which influence safety-related behaviour at work. This safety-related behaviour 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 major injuries at the top (the exact ratio varying according to the variant of the technique adopted). It is often only 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 and the more serious accidents. Therefore, near misses are also preventative opportunities for the Safety Practitioner as they indicated which behaviour patterns need to be changed before luck runs out and a serious accident occurs.

However, it is important not to jump to the conclusion that incorrect behaviour patterns on behalf of individual employees equates directly with fault. Often the behaviour patterns are a result of organisational 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 all operational and emergency situations, and to replace those which cannot be followed with new rules and procedures that can be followed. Employees will then need to be trained in the new rules and procedures and monitoring systems will need to be introduced in order to ensure that they are, in fact, being followed. This approach requires a fairly heavy resource commitment on behalf of the organisation.

It is within this context that the Health and Safety Executive’s publication Reducing Error and Influencing Behaviour (HSG48) needs to be considered.

Reducing Error and Influencing Behaviour is in fact a substantial revision of the previous publication Human Factors in Industrial Safety and it is good to note that the Health and Safety Executive have noted the perceptual failings with regard to the previous publication – notably the fact that the term industrial limited 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 the selection of examples mainly relating to heavy industry). The new publication is clearly directed at all workplaces 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 at work 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.

In order to begin to develop a fully-fledged human factors strategy, the above factors should be considered 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 and incidents are the result of human error by the worker in the front line. "Attributing incidents to human error has often been seen as a sufficient explanation in itself and something which is beyond the control of managers. This view is no longer acceptable to society as a whole. Organisations must recognise that they need to consider human factors as a distinct element which must be recognised, assessed and managed effectively in order to control risks".

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

• Illogical design of equipment, instruments.
• Constant disturbances and interruptions.
• Missing or unclear instructions.
• Poorly maintained equipment.
• High workload.
• Noisy and unpleasant working conditions.

• Low skill and competence levels.
• Tired staff.
• Bored or disheartened staff.
• Individual medical problems.

• 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 into various types involving errors and violations. The following diagram illustrates this point:

The above model operates with the notion that all human failures can be categorises as either human error or violations depending on whether or not intention was involved with the failure. A human error being an action or decision which was not intended, but which involved a deviation from an accepted standard and which led to an undesirable outcome. Errors can be sub-divided into slips, lapses and mistakes.

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 should therefore identify where such factors are present and assess the likelihood of errors taking place and their consequences. Error control and reduction should take into account the need: To address the conditions and to reduce the stressors, To design plant and equipment in order to either prevent slips or lapses occurring or to increase the chances of detecting and correcting such errors, To ensure that arrangements for training are effective, To design jobs to avoid the need for tasks which involve complex decisions, diagnoses or calculations, To provide proper supervision, To check that job aids such as procedures are clear, concise, available, up-to-date and accepted, To monitor that the measures taken to reduce error are effective.

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

Developing a Strategy

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

According to the Contract Research Report: " In terms of personality, the evidence presented in this review suggests that extroversion and neuroticism are linked to increased accident vulnerability, but does not suggest why this should be so. It is plausible that while neuroticism may be associated with accidents via an increased vulnerability to stress, extroversion may increase an individual’s willingness to take risks. The model of accident liability attempts to integrate the findings of research into individual differences in accident liability with more recent research into the various forms of human failure and their role in accident causation. The model offered also attempts to link psychological, organisational and 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 be remembered that the personality characteristics that give rise to safe performance in one situation may prove detrimental in another situation. For example; a rigid approach to rules and procedures may be required in most instances, but a more flexible approach be required in an emergency situation. Such factors need to be considered when risk assessments are performed in relation to normal operations and emergencies.

Where the safety culture is clear and positive, group pressure can even influence an unstable extrovert not to take risks. However; where the culture is ambivalent, and linked to performance targets and deadlines, 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 when developing a strategy based upon the control of organisational, job and individual factors which can lead to human failings:

Have you:

• Identified and analysed critical tasks?
• Evaluated the employee’s decision-making needs?
• Evaluated the optimum balance between human and automatic systems?
• Applied ergonomic principles to the design of equipment displays including displays 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 working environment including the workspace, access for maintenance, lighting, noise and thermal conditions?
• Provided the correct tools and equipment?
• Scheduled work patterns and shift organisation to minimise impact on health and safety?
• Considered how to achieve efficient communications and shift handover?

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