Anyone can make a mistake. Which means you can't ignore the human factor in accidents in the workplace. But it's not always as simple as blaming loss of concentration, clumsiness, or some other seemingly obvious case. And it's important to discover the real reason for the accident - because then it's far easier to find an effective way to stop it happening again.
People cause accidents. But quite often, something causes the person to cause the accident. For instance, active failures and latent conditions can both lead to human error or violations of prescriptive procedures.
Why Did it Happen?
An active failure is essentially something someone does, or the prevailing conditions, which lead to the incident or accident occurring. An active failure will usually involve frontline staff, and the consequences will be immediate. But the good news is that active failures can often be prevented by design, training or operating systems.
A latent condition can be a result of managerial influences and social pressures within the organisation. In other words, it’s the culture of ‘the way we do things around here’, and it can influence the design of equipment or systems, and define inadequacies in supervision.
Latent conditions are latent because they tend to be hidden until an event triggers them off. And when it does, the latent conditions can lead to a latent failure – whether that’s a human error or a violation. Latent failures may also occur when several latent conditions combine in an unforeseen way.
Active failures and latent conditions both show that we can all make errors, no matter how much we have been trained, how much experience we have, or how motivated we are to do it right.
There’s more than one way that humans can cause accidents. Fortunately there’s also more than one way they can help to lessen the consequences.
The first way we can actually directly cause an accident is known as ‘incident’.
- A failure or error by a person can cause an accident. Of course, people tend not to make errors deliberately, but – without knowing it – we are often set-up to fail. This may be because of the way our brain processes information, or through our training, through the design of equipment and procedures, or even through the culture of the organisation we work for.
Even when people know the risks, they can still make disastrous decisions. We can also misinterpret a situation and act inappropriately as a result. Either of these can lead to the escalation of an incident.
The good news is, an individual (sometimes even the same individual) can intervene to stop potential accidents. We may be error-prone, but we are also often resourceful and ingenious.
If the incident is a life-threatening one, loss of life can be limited through an effective emergency response from operators and crew. Emergency planning and response, including appropriate training, can significantly improve rescue situations.
The consequences of human failures can be immediate or delayed. Those with immediate consequences are known as active failures, which are usually made by frontline people such as drivers, control room staff or machine operators. In a situation where there is no room for error, active failures have an immediate impact on health and safety.
Failures with delayed consequences are known as latent failures, and are made by people whose tasks are removed in time and space from operational activities. So they may be designers, decision makers, or managers, for example. Latent failures are typically failures in health and safety management systems (design, implementation or monitoring), such as:
- Poor design of plant and equipment
- Ineffective training
- Inadequate supervision
- Ineffective communications
- Inadequate resources (e.g. people and equipment)
- Uncertainties over roles and responsibilities
Latent failures are a danger to health and safety that’s as great or greater than an active failure. However, they are usually hidden within an organisation, until they are triggered by an event likely to have serious consequences.
Risk Reduction - The Truth Is out There
When an accident involves human failure, all too often there is not enough investigation into why the human failure occurred. But unless you find out the immediate and the underlying causes of an accident, how can you design effective control measures to prevent it happening again?
Typical examples of immediate causes and contributing factors for human failures are:
- Illogical design of equipment and 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, bored or disheartened staff
- Individual medical problems
Organisation and Management Factors
- Poor work planning, leading to high work pressure
- Lack of safety systems and barriers
- Inadequate responses to previous incidents
- Management based on one-way communication
- Deficient co-ordination and responsibilities
- Poor management of health and safety
- Poor health and safety culture
Establishing which of the above factors, or combination of factors, led to the accident, is not a means of apportioning blame. It’s a means of doing your best to ensure avoiding a repeat. And that’s surely the most important goal.