Is 'human error' ever acceptable as a cause?
I find this topic fascinating. Having read all opinions so far, I am going to be a bit foolish and try to condense what I have read into two opposite but complimentary notions:
1. "Human error" is a weak conclusion, because all we can go a step further to find out why people make decisions and try to engineer out the opportunities to, or consequences of, making these "mistakes".
2. Unreliability of humans is "inevitable". We are, after all, "general practitioners" in this world. We have wide skills but can't be perfect at any of them.
What I see in safety management are conversations dominated by an approach focussed almost entirely on managing hazards. People aren't allowed to "own" risk. We want to withhold ownership, because we are responsible and may be personally liable. Something a bit different is needed. We rarely see conversations about enabling workers to take ownership of whatever residual risk remains after what is "reasonably practicable" has been done.The post above by Brian Parker about a driver not securing a load is a good example of where we cannot hold onto the ownership. As Brian says, the drivers work alone and the variables of securing loads are huge, if not infinite.
I don't at all like using "personal accountability" as a way of scaring workers into thinking about what they are doing. It's just a type of blaming. But I think the concept of risk is something all humans are naturally good at. All animals, particularly wild ones do it, and they are highly conservative about it.
When I give training in hazard and risk management, I get groups to intuitively rank hazards as to "how bad" they are. Then, we do the risk calculating thing (two versions) and invariably, the rankings come out very similarly compared to the intuitive way. We may have created risk assessment tools, but they are no use at all minute by minute. The good news is that we use that intuition constantly and we're good at it. But we don't like to talk to workers about how to take reasonable risks.
I'm suggesting that a no-blame conversation should be going on all the time that literally lets go part of the control and lets workers own it. When I was teaching my daughter to drive, she had a tendency to feel stressed while waiting to pull out of T junctions. Confidence grows with experience, but what I said to her was classic risk management: "It may be unlikely that you will get T-boned pulling out, but if you do, you could be dead. So unless you have almost 100% certainty, don't do it". Notice, I didn't say "You'd be stupid to rush, so I don't ever want to see you do that". I think, (at least I hope), I gave her ownership and some basic thinking skills.
I believe that sort of approach is missing in traditional safety management. It would take time, but we're only talking about residual risk. I'm not flying this as a panacea, but I believe it has its place. It's about instilling responsibility, not accountability, giving recognition and support to workers when they haven't yet reached a level of certainty, and placing importance on their own decision-making. I'd be interested in other comments about this suggestion.
I have just completed a synopsis of heath and safety event data for a class 4/5 driver employed with us 25+ years and have 7 instances of human error resulting in unsafe driving technique which incude 2x fail to give way and turn into oncoming traffic (one of which results in ambulance having to be called), 2x drive with rear doors unlatched resultng in damge to parked vehicles, an operate forklift when approached by person on foot, stops the vechicle talks with the person then looks away and drivers forward over the pedetrians foot, latest incident involves drive over concrete bollard when exiting fuel bowser resulting in damaged wheel, rim and underside of truck. Licene to drive heavy vehcile is current, has completed external hazard managment and risk assessment training, had multiple non compliance include final warning. Where to from here I wonder?
That's a real basket load of issues but it's not clear if the 7 events were over the entire 25+ years, or a more recent trend. If the latter, is it age, health, stress, fatigue, work pressure? Have some job factors changed for him? Is he dissatisfied about something?
Either way, I'm sticking with my assertion that everything, from forgetting something (rear doors), to intentional (failing to give way), has cause(s), but they may be beyond our current knowledge to identify or correct. Have you talked to him openly and without blame to see if he has anything going on in his life that is pressuring or distracting him?
Human Failures lead to errors, either action errors or thinking errors, human error does not exist, action based slip, memory based lapse, rules based mistake, knowledge based mistake are failures of both humans and systems.
Robyn's post raises some interesting issues, and maybe I'm taking the conversation down a side path - but an important one for the transport sector.
We have a rapidly aging workforce which is expanding - and yet has insufficient young people coming in to replace the existing drivers as they retire. All people's driving deteriorates over time for a multitude of reasons. In driver training we call this 'Slippage'. One important reason is the general lack of oversight and feedback. The deterioration in drivers' behaviours generally accelerates in their 50's. (reflect on your parents' driving for example). Again there are many reasons for this.
Some we need to consider are:
Reduced peripheral and focused vision (particularly in poor light), and hearing
A slowing down in mental processes means we take longer to make decisions, increasing reaction times
Deterioration in physical condition also leads to increased reaction times
More susceptible to 'Information Overload' leading to reduced 'Situational Awareness' and increased confusion, also affecting reaction times and increasing the incidence or 'Errors'
Shorter attention spans leads to reduced concentration and increasing the incidence or 'Errors'
More easily distracted also leads to reduced concentration and increasing the incidence or 'Errors'
Once these issues are detected and the driver is aware of how they affect their driving, they can be trained in techniques to enable them to cope with them - up to a point. This essentially means training them to 'drive to the conditions', where the dominant condition is now internal rather than external as we traditionally consider the term. I won't take up more space here discussing how to do this, but if you are interested you can contact me directly at
So what are we doing about this at Specialised Lifting and Transport Group?
We conduct a pre-employment driving assessment to set a benchmark for the driver's skill level. Because all our work is considered 'High Risk', we don't employ low performing drivers. During their on boarding process we provide remedial training to correct the deficiencies we detected, and reassess after 1 month and 3 months to confirm they have integrated the changed behaviours into their driving. We then follow up with bi-annual on-job assessments that measure their performance over all aspects of their work - not just their driving. Any deficiencies are corrected with remedial coaching after each assessment.
Some perspective on this from Dekker.
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