A factory worker decides to by-pass an electrical lock out procedure (because it “takes too much time” and “production goals need to be met”). This decision could result in the worker paying the ultimate price: electrocution resulting in death.

Jim Withers, PhD, CIH, deals with this sort of human error all the time as Safety Director at Sauer Danfoss, the global manufacturer and supplier of hydraulic and electronic components. But his view is influenced by Human Performance Improvement (HPI), as taught by Dr. Todd Conklin of the Los Alamos National Laboratory ¹.

Jim points out that while 90% of safety-related mistakes are human error, less than a third of those are related directly to the individual (such as a trip or fall), while the other 70% are caused by something in the organization like a lack of training or supervision.

OLD VIEW:
Human error is a cause of accidents.
NEW:
Human error is a symptom of trouble deeper inside a system.

A belief in individual errors means investigations will naturally focus on identifying and blaming someone. The HPI goal is to identify error-likely situations, so that systems can be put in place to ensure errors don’t have harmful consequences.

OLD VIEW:
To explain failure, investigations must seek failure. Find people’s inaccurate assessments, wrong decisions, and bad judgments.
NEW:
To explain failure, do not try to find where people went wrong. Find how people’s assessments and actions made sense at the time, given circumstances that surrounded them.

Investigation of an error can focus on “they could have…, they failed to …, if only they had…”—pretty easy with hindsight. HPI suggests reconstructing the event as it unfolded around the worker (their process, information available, etc.) so you discover what the worker did and why they did it.