The facts of life – birth, death, taxes – and mistakes!

Errors, mistakes and violations play a key part in most workplace incidents. According to an SHP report, around 90% of incident reports indicate human failure is to blame. But what are the factors that underlie these errors and violations, and why do investigations often stop when they identify human failure and not look at identifying and fixing the underlying factors? For example underlying factors like the potential for people to get distracted during tasks, or controls and displays that are counterintuitive, or uncomfortable environments that lead people to rush to get jobs done.

Reasons why the underlying causes of mistakes get left – and go on to cause the same mistakes again.. and again..

One possible reason why underlying factors are often left undiscovered (and unresolved) is that there is little Human Factors guidance for general industry, including SMEs. Human Factors in relation to health and safety means considering the tasks people are doing and designing the job and the environment to accommodate the needs of the individuals, and to optimise their performance. This means getting a broad range of factors right, to make sure people are less likely to make mistakes or cut corners when it comes to safety. Historically Human Factors been seen as something high-hazard industries, airlines etc. think about, rather than general industry.

Based on incident investigations I have been involved in at the Health & Safety Executive, very often incidents happened because someone had done something that was unsafe, and the dutyholder hadn’t foreseen that they might do that. Foreseeability of human failure was (and always will be) a huge issue for all types of businesses. Court cases, prosecutions etc. very often hinge on whether the act that directly led to injury was foreseeable.

Why is human factors so important for SMEs in particular?

Human failures (errors, mistakes and violations directly causing health and safety incidents) costs SME’s a huge amount of money annually. Here’s how it adds up:

SMEs are a vital part of the UK economy, accounting for around 60% of private sector employment (15.6 million people). In total there are approximately 10.5 million SMEs employees in the UK. In that 10.5m (and based on an even distribution of people in sectors), around 4.5 million are employees in construction, manufacturing, transport storage and communications, agriculture, hunting and forestry, hotels and restaurants – all sectors that can present significant workplace risks.

Based on a 3% workplace injury rate average in these sectors, this means around 135,000 injuries per year for SME employees. Using the 90% blame rate for human error, and a direct correlation of incidents to injuries, this means around 121,500 injuries related to incidents where human error is identified as being to blame – costing businesses a massive £145.8 million each year (based on a cost of £1200 per injury for employers).

These figures are estimates of course and I have explained the assumptions they are based on, but even with a large margin of error, this shows that human failure and human factors are hugely important issues for SMEs generally. The £145.8m figure also don’t include incidents and injuries linked to human failure in the other SME industry sectors such as retail and care.

On top of this is the likelihood that small companies may suffer (proportionally) more financially than large ones, when an employee is injured. And finally, SMEs particularly micro and small businesses (up to 49 employed) are often close knit and a serious incident / injury can have a real cultural impact on the business – damaging employer relations, destroying trust and creating difficult environments to work in.

What can we do – people make mistakes yes?

There is Human Factors guidance available, but it is mainly aimed at high-hazard sectors (oil and gas, nuclear etc.). To address this gap we have developed a checklist tool and guidance. Our document gives you a straightforward basis to start thinking about the possible underlying causes of human failure that might be in your workplace or in the tasks. Our guidance is aimed at SME’s and the examples in it are relevant to a wide range of general industries.

People make mistakes, forget to do things, and do things they were told not to, but these are not completely unpredictable. If underlying issues are dealt with pre-emptively we can reduce the likelihood of failures that lead to incidents and injury.

The aim of our checklist and guidance is to help companies identify issues that could increase the likelihood of human errors / violations, so that those issues (sometimes referred to as Performance Shaping Factors can be optimised (in other words altered or removed altogether to reduce the likelihood of errors before they happen).

Click here to download our interactive Human Factors checklist for SMEs (pdf file).

It is unfeasible in most cases to predict the full range of specific human failures that could happen, but if you get your performance shaping factors right, you can prevent incidents that you may never have even have thought of. I think of this like fixing a fishing net. If you fix the net (your performance shaping factors) you might not catch anything (stop a failure from happening), but your chances of catching something are a lot higher (you might catch lots!). If you go fishing, it seems sensible to have a fixed net anyway! The only difference is that in practice you rarely see the fish you catch (failures you prevent). You tend to only see the ones that get through an unfixed net (failures that lead to incidents).

The other commonly used analogy is the swiss-cheese / layers of defense model of incident prevention – click here for more information.

5 Key messages

  • Don’t ever stop an accident / incident investigation at ‘human error’. Always ask why that error happened. This is neatly summed up as a ‘5 whys’ analysis which is a simple form of root cause analysis aimed at uncovering the underlying factors that may have led to a human failure. But don’t stop at just 5 whys, if you can keep going then you should!

  • Make effective use of near-miss data, and make sure there is a just and fair approach to incident investigations. This doesn’t mean a ‘no-blame’ culture, but a reasonable approach that takes account of key message 1.

  • Don’t ever assume that employees know how to stay safe, or that they won’t take shortcuts when it comes to health and safety. Don’t assume people will always follow procedures and carry out safety steps in tasks to the letter.

  • Provide some level of supervision for all staff in terms of safety compliance, even if they are very experienced and even if they work remotely.

  • Proactively manage ergonomics and human factors, to fix potential underlying causes of human failure before they actually result in an incident.