What are the root causes of human error?

accident injury report

What are the root causes of human error?

While every workplace is unique, human errors happen at all them. They can never be eliminated, but they can be minimised. Research into the Oil and Gas industry has found that most human errors can be attributed to 1 of 3 categories. They are:

  • Process and procedure non-compliance
  • Lack of safety culture adherence
  • Breakdowns in safety critical communications

Understanding these 3 categories is a key step to addressing human error, the next step is knowing how to address them.

Historically, in the Oil and Gas industry, human errors haven’t been dealt with in a ‘human factors-friendly’ way e.g. the employee has been blamed and disciplined. Often the solution is to instead address the overarching root causes (Gordon, 1998; Sanders, 1987; Wickens, 2004).

How can Human factors help? It allows for a holistic approach to non-technical error. Our expertise highlights operator behaviours and limitations such as stress and strain, fatigue, cognitive load, communications, distractions, attention focus, situation awareness and other critical variables required to maintain operational safety. Addressing these previously disregarded factors allows for a user-centred approach when re-designing processes and procedures to consider the capabilities and limitations of the human tasked with following the instructions (Endsley, 1995; Hancock & Parasuraman, 2002; HSE, 2012).

Clear communication is critical

To take the example of communications: IHF reviews safety-critical communications frequently – highlighting instructions which are difficult and confusing to follow, do not represent a logical order, are located over multiple documents, out-dated and do not clearly reflect the current operational standards for ‘doing things’ (Thomas & Carroll, 1981; Reason, 1995).

Deconstructing and rebuilding procedures

Rebuilding procedures from the perspective of the end-user allows for human factors to be taken into account. Information can be ordered in a manner which accurately represents the task steps within the procedure, dangers and hazards can be highlighted as initial, critical information and instructions can be worded, presented and broken down in a manner which will not ‘overload’ the end-user (HSE, Shackel, B, 1991; HSE, 2012).

Summary

While this is a brief example discussing just a few human factors components and applications, it serves to highlight the necessity of the field as a tool to manage operational safety, human-error and accident/near miss occurrence. A human factors approach should be taken no less seriously than the physical integrity of workplace tools and equipment.

References

Endsley, M. R. (1995). Toward a theory of situation awareness in dynamic systems. Human Factors: The Journal of the Human Factors and Ergonomics Society, 37(1), 32-64

Gordon, R. P. (1998). The contribution of human factors to accidents in the offshore oil industry. Reliability Engineering & System Safety, 61(1), 95-108.

Hancock, P. A., & Parasuraman, R. (2002). Human factors and ergonomics. Encyclopedia of Cognitive Science.

HSE, (2012). Human factors that lead to non-compliance with standard operating procedures. Health & Safety Laboratory for the HSE.

Wickens, C. D., Gordon, S. E., & Liu, Y. (2004). An introduction to human factors engineering.

Reason, J. (1995). Understanding adverse events: human factors. Quality in health care, 4(2), 80-89.

Sanders, M. S., & McCormick, E. J. (1987). Human factors in engineering and design . McGRAW-HILL book company.

Shackel, B. (1991). Usability-context, framework, definition, design and evaluation. Human factors for informatics usability, 21-37.

Thomas, J. C., & Carroll, J. M. (1981). Human factors in communication. IBM Systems Journal, 20(2), 237-263.