Understanding Human Error and Risk Tolerance as Causes of Workplace - - PowerPoint PPT Presentation

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Understanding Human Error and Risk Tolerance as Causes of Workplace - - PowerPoint PPT Presentation

Sep 06, 2022 278 likes •877 views

Understanding Human Error and Risk Tolerance as Causes of Workplace Accidents Glyn Jones, M.A.Sc, P.Eng, CIH, CRSP EHS Partnerships Ltd. 2 3 Schuylkill County (pronounced SKOO-kill) 4 Alberta sees five fatal workplace accidents in one week

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Understanding Human Error and Risk Tolerance as Causes of Workplace Accidents

Glyn Jones, M.A.Sc, P.Eng, CIH, CRSP

EHS Partnerships Ltd.

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Schuylkill County

(pronounced SKOO-kill)

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Alberta sees five fatal workplace accidents in one week

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Mo Tires Incident

"This is the first time in 75 years, and hopefully the last," said Bill Wright, the Manager of Mo Tires, of the fatality. "People make mistakes, and sometimes there is extreme result of that," added Wright. "What we have to send a message to workers to be on their toes, be careful, follow the procedure, follow the rules. Nobody's exempt from having something bad

  • happen. A lot of times people take things for granted, and a lot of

us have to be more careful."

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Case study 1 – Flash fire in maintenance shop

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Case study 1 – Flash fire in maintenance shop

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Case study 1 – Flash fire in maintenance shop

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Case study 2 – Zamboni driver injured

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Case study 2 – Zamboni driver injured

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Case study 2 – Zamboni driver injured

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Outlet chute of the vertical auger

Case study 2 – Zamboni driver injured

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Case study 2 – Zamboni driver injured

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Recognizing the 3 ingredients for safety

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OHSMS – Systems Build for Performance

▪ OHS Policy ▪ Hazard Assessment and Control ▪ Work System

▪ Safe Work Practices ▪ Safe Job Procedures ▪ Company Rules ▪ Personal Protective Equipment - ▪ Preventative Maintenance

▪ Training and communication ▪ Workplace Inspections ▪ Investigations and Reporting ▪ Emergency Preparedness ▪ Record Keeping ▪ Legislation ▪ Health and Safety Representation and Joint Health and Safety Committee ▪ Management Review and Continuous Improvement

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OHSMS continuous improvement

PLAN ACT DO CHECK

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What jobs result in accidents?

"Jobs with high task demands, and little control over how the tasks are to be completed, are the most likely to result in employee disability."

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The real cause of accidents… Workplace accidents are a result of:

  • Human errors;
  • Situational aspects; and
  • Environmental aspects;
  • f the work and workplace.
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Causes of workplace incidents

▪ Line of fire ▪ Energy

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Forms of energy

Gravitational Kinetic Thermal Biological Chemical Water Electrical Radiation Animal Stored potential energy Noise Multiple kinds of energy

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The Real Problem

Workers, some:

▪ are weak ▪ don’t know ▪ don’t care ▪ get tired ▪ forget ▪ are lazy ▪ are stressed ▪ don’t follow rules ▪ are easily confused But you need people to run your organization, so….we need to figure this out!

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Simplified Risk Assessment

ASK THE SIMPLE RISK QUESTIONS!

WHY am I doing this at all? WHAT could go wrong? HOW could it affect me or others? HOW likely is it to happen? WHAT can I do about it?

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Factors that cause/contribute to accidents

▪ The systems approach – accidents occur because of the interaction between system components ▪ Direct causal factors in safety:

  • 1. The employee performing a task
  • 2. The task itself
  • 3. Any equipment directly or indirectly used in the task
  • 4. Other factors – social/psychological and environmental
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The Social environment

▪ Human behavior is influenced by social context

Social norms, management practices, morale, training, incentives (e.g. construction workers will not wear safety gear if no one else is) Creates the mechanism for “normalized deviance”

Normalization of Deviance

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Social Environment – Assess Risk

▪ Human behavior is influenced by social context

Social norms, management practices, morale, training, incentives Creates the mechanism for “normalized deviance”.

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Basic Errors

Unsafe Acts

Unintended Action Intended Action

Slip Lapse Mistake Violation

Attentional Failures Rule-based or Knowledge-based Mistakes Routine violations Exceptional violations

Human error taxonomy

James Reason (1992)

Memory Failures

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Attentional / Memory Failures

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Accident caused by failure to secure

November 10, 2004 - Calgary

Rule-based or Knowledge-based Mistakes Routine violations Exceptional violations

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Routine Violations

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Exceptional Violations

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Rule-based or Knowledge-based Mistakes Routine violations Exceptional violations

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Chemical exposure by inhalation, ingestion, and skin absorption

Rule-based or Knowledge-based Mistakes Routine violations Exceptional violations

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Rule-based or Knowledge-based Mistakes Routine violations Exceptional violations

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Rule-based or Knowledge-based Mistakes Routine violations Exceptional violations

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Rule-based or Knowledge-based Mistakes Routine violations Exceptional violations

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Simplified Risk Assessment

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How to manage workplace safety

Employees need to be able to:

  • 1. Perceive risks when they arise
  • 2. Understand the consequences of the risk
  • 3. Make a decision to not tolerate any risk

that is inconsistent with the Corporate risk posture.

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Risk Posture

Risk Posture definitions:

  • 1. A person’s ability to accept (or handle) exposure to

defined levels of uncontrolled risk.

  • 2. Is the relative ability to accept a specific level of

uncertainty with respect to negative outcomes associated with well defined work activities.

Cautious of risk Oblivious to risk

Where is your company?

Risk Averse Accepting of Risk

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Risk Posture

Cautious of risk Oblivious to risk Risk Averse Accepting of Risk

Where are your employees?

Risk Posture definitions:

  • 1. A person’s ability to accept (or handle) exposure to

defined levels of uncontrolled risk.

  • 2. Is the relative ability to accept a specific level of

uncertainty with respect to negative outcomes associated with well defined work activities.

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Risk tolerance

Probability Impact Risk tolerance

Do not accept the risk Accept the risk

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Factors that Increase Risk Tolerance

  • Overestimating Capability/Experience
  • Familiarity with the Task
  • Voluntary Actions and Being in Control
  • Confidence in the Equipment
  • Confidence in Protection and Rescue
  • Potential Gain/Profit from Actions
  • Role Models Accepting Risk

Reference: ExxonMobil Human Factors Center of Excellence

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Factors that Reduce Risk Tolerance

  • Understanding the Seriousness of the

Outcome (explain the “why”)

  • Personal Experience with Potential

Outcome

  • The Cost of Non-Compliance

Mark McMorris Reference: ExxonMobil Human Factors Center of Excellence

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Recipe for Safe Work – Zero Harm

  • A good management system
  • Competent workers
  • Good communication
  • Leadership from everyone
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We need to build error-tolerance into all of our systems

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Task design

▪ Design tasks with working memory capacity in mind

Equipment design

▪ Minimize perceptual confusions/ease of discrimination

▪ E.g., airplane controls that feel like what they do (flaps, wheels)

▪ Make consequences of action visible/immediate feedback

▪ E.g., preview window in some software programs

▪ Lockouts – design to prevent wrong actions

▪ E.g., car that will not let you lock door from outside without key

▪ Reminders – compensate for memory failures

▪ E.g., ATM reminds you to take your card

Error Prevention / Remediation

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Training

▪ Provide opportunity for mistakes in training, so can learn from them (e.g., simulations)

Assists and Rules

▪ Checklists to follow (e.g. pilot’s pre-flight checklist)

Error-tolerant systems

▪ System allows for error correction or takes over when

  • perator makes serious error/redundancy of control

(e.g., Undo button/belts and suspenders)

Error Prevention / Remediation (cont’d)

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What to remember…

  • Human behaviour can be predicted with reasonable

accuracy

  • Correctly integrating human factors thinking into your

accident investigation process will reap rewards – just look at the contemporary causation theories

  • Separating error, mistake, and violation represents a

highly valuable first step

  • Employee selection and competency development is

a big part of error risk management

  • Think “error-tolerant” systems
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Recognizing the 3 ingredients for safety

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A final thought…(almost)…

The most powerful influence on human behaviour is

  • utcome.

Therefore, managing human failure requires a high degree of corporate honesty:

  • What behaviour is really rewarded?
  • How are we managing mixed messaging?
  • Will we use “real” performance management?
  • Are we willing to look at organizational factors, especially

when we see rule breaking?

  • Are we willing to make the investments that are needed to

prevent reoccurrence?

  • Are we willing to strive for objectivity and pragmatism?

Remember – you ‘own it’ anyway, so ‘manage it!’

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Leadership need is driven by system design

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Understand the issue but focus on solutions…

Leadership development is the necessary medicine to improve the safety climate, advance the safety culture, and encourage proper and safe behavior…everyday. Most human error is behavioral and is a symptom of a weak safety culture.

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It is all connected…

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Questions? Please feel free to contact me directly