Human error is often identified as a cause for workplace incidents and injuries. In his Safety 2014 concurrent education session, Tom Harvey delivered a high-energy presentation that highlighted the failures of establishing causation by focusing on symptoms of the system (e.g., incidents, mistakes, violations, injuries, near hits, property damage). Instead, Tom explained, the focus should be on situational error traps, drift error traps, leadership, culture, job design, ineffective tool use, system breakdown and organizational weaknesses. Situational traps are defined as time pressure, distraction or interruption, multitasking, over confidence, vague guidance, first shift/last shift characteristics, peer pressure, job scope change, physical environment and mental fatigue.
Normal drift traps that creep in over time include temperature change, shortcuts, extending tool and machinery preventive maintenance, conflicting values, bad habits and vague policies, ineffective training, flawed procedures, faulty equipment, faulty technology, design and engineering, and lack of accountability. These situational and error drifts get larger over time if not addressed, and this can result in a higher frequency of mishaps with greater severity.
Tom highlighted several tools that can be used to correct the causes of increased frequency and severity:
- Question attitudes, confidence and complacency.
- Conduct job plan analysis.
- Plan tasks from 5 to 30 minutes and conduct pretask briefs.
- Self-check before and while working.
- Develop effective communication.
- Use procedures.
- Perform place keeping. Don't allow interruptions to cause you to forget where you are in the task steps.
- Peer check. Watch out for co-workers.
- Perform coaching with constructive feedback.
- Conduct after-task reviews.
