The human element
The cost of human error
The UK Club identified in its first Analysis of Major Claims in 1990 that ‘human error’ accounted for 58% of all its claims over US$100,000. In the years since, despite marked falls in certain identified causes (for instance, structural failure), human error has remained stubbornly high as the prime cause of accidents and claims. As a consequence, the Club has for some years sought a methodology for both defining and analysing human error in the maritime context, in the hope of finding ways of tackling this seemingly intractable problem. A close study of the work of researchers at Manchester and Leiden Universities in the 1990s, on behalf of Shell, has resulted in the Club adopting their methodology and producing its most complex DVD to-date in order to illustrate the underlying concepts.
 The DVD No Room for Error graphically illustrates a proven methodology that shipowners can use to identify the propensity for human error to arise in their shipping operations. It also gives the Club the tools with which to analyse its extensive statistics to show where – and why – human error is most likely to arise.
No Room For Error seeks to differentiate between the acts and omissions of people at the sharp end, and latent system faults generated by the culture created and the decisions made by those in authority in the shipowner’s offices. Unlike the Club’s previous videos and publications aimed at addressing trade specific issues, No Room for Error is intended to form part of, or to supplement, a company’s long-term training programme as well as to stimulate debate within the company aimed at reinforcing the effectiveness of the ISM Code through the development of a permanent and robust safety and environmental protection culture.
Human error
Over the past two decades, there has been a growing appreciation of the many and varied ways that people contribute to accidents in hazardous industries, or simply in everyday life. Not long ago most of these would have been lumped together under the catch-all label ‘human error’. Nowadays it is apparent that this term covers a wide variety of unsafe behaviours.
Most people would agree with the old adage ‘to err is human’. Most too would agree that human beings are frequent violators of the ‘rules’ whatever they might be. But violations are not all that bad – through constant pushing at accepted boundaries they got us out of the caves!
Assuming that the rules, meaning safe operating procedures, are wellfounded, any deviation will bring the violator into an area of increased risk and danger. The violation itself may not be damaging but the act of violating takes the violator into regions in which subsequent errors are much more likely to have bad outcomes. This relationship can be summarised quite simply by the equation:
The resultant situation can sometimes be made much worse because persistent rule violators often assume, somewhat misguidedly, that nobody else will violate the rules, at least not at the same time! Violating safe working procedures is not just a question of recklessness or carelessness by those at the sharp end. Factors leading to deliberate non-compliance extend
well beyond the psychology of the individual in direct contact with working hazards and include such organisational issues as:
- The nature of the workplace
- The quality of tools and equipment
- Whether or not supervisors or managers turn a ‘blind eye’ in order to get the job done
- The quality of the rules, regulations and procedures
- The organisation’s overall safety culture, or indeed its absence
Violations are usually deliberate, but can also be unintended or even unknowing. They can also be mistaken in the sense that deliberate violations may bring about consequences other than those intended, as at Chernobyl. In this case, out of the seven unsafe acts (active failures) leading up to the explosion, six were a combination of a rule violation and an error (a misventure). Here was a sad and remarkable case in which a group of well-motivated and exceedingly expert operators destroyed an elderly but relatively well-defended reactor without the assistance of any technical failures.
The distinction between errors and violations is often blurred but the main differences are shown in the table below:
While errors may be simple memory or attentional failures, they can be exacerbated by:
Routinisation – the mark of a craftsman whereby the individual becomes so expert at exercising a particular skill, that he/she no longer consciously thinks about it allowing the mind to wander and the unexpected to happen – drivers who regularly travel the same route to the station each day suffer from this – ‘am I here already?’
 Normalisation – the process of forgetting to be afraid – interestingly most accidents on mountains happen on the way down from the summit – only a relatively small number happen on the way up.
Intrinsic hazard – no matter how well you defend yourself the dangers ‘out there’ never go away – move outside your protective ‘bubble’ and something or someone will get you!
Creeping entropy – systems, policies and procedures grow old or fail to adjust to changing external factors thus increasing the propensity for accidents to happen.
Murphy’s Law – if it can happen it will happen, but there is also Schultz’ Law. Mr Schultz merely said that Murphy was an optimist!
The rules
We have already spoken about breaking the ‘rules’ but what precisely are they? Basically they are procedures written to shape people’s behaviour so as to minimise accidents. They are, if you like, standards designed to form part of the system defences against accidents. Defences are installed to protect the individual, the asset or the natural environment (all ‘objects of
harm’) against uncontrolled hazards and generally appear in two forms:
- ‘Hard’ defences, provided by fail-safe designs, engineered safety features and mechanical barriers.
- ‘Soft’ defences provided by procedures, rules, regulations, specific safety instructions and training.
To remain totally relevant and to avoid falling victim to ‘creeping entropy’, procedures are continually being amended and updated to cover matters such as changed working conditions, new legislation, new equipment and most particularly, to prohibit actions that have been implicated in some recent accident. Following an accident how often have you heard people
(usually senior) exclaim “and what did the procedures say?” It is a matter of fact therefore that over time these procedural changes become increasingly restrictive yet the actions necessary to get the job done haven’t changed and often extend far beyond these permitted behavioural boundaries.
 Ironically then, one of the effects of continually tightening-up procedures in order to improve system safety is to increase the likelihood of violations being committed. The scope of permitted or allowable action shrinks to such an extent that the procedures are either routinely violated or violated whenever operational necessity demands. In either case, the procedures are often regarded as unworkable by those whose behaviour they are supposed to govern. Whereas errors can arise from various kinds of informational under-specification, many violations are prompted by procedural over-specification – a classic own goal you might say!
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