When you ask people what is more important: hazards or human error you will get many different perspectives. This article explores those perspectives and introduces a new way of thinking about hazards and hazardous energy.
If you ask people what’s more important, hazards or human error, you will hear many different perspectives. Many managers, including some safety professionals, think that industrial safety is all about, or at least mostly about the “hazards”, things that are inherently dangerous like a flame, toxic chemical or rotating saw blade, something that needs to be contained, guarded or controlled.
And certainly, from a regulator’s point of view, hazards—and the aforementioned controlling or guarding of them—is basically what the inspection is all about. So, it’s easy enough to see why some managers and safety professionals think hazards are so important. In addition, engineering controls, ventilation systems, guarding and personal protective equipment all cost money. Since these costs do not improve production or quality directly, it’s also easy enough to understand why many managers think they are a “sunk cost” or just a “cost of doing business”, which reinforces or helps to support the paradigm that industrial safety is primarily about the hazards.
However, there are other people who would go even further – and say that human error is inevitable; that it’s a result, not a cause; and that it is not important in a well-managed safety system… and then they go home and tell their kids to be “careful”. Or, if they do get hurt: try to be “more careful” next time. Hypocrite or wrong paradigms?
Well, hypocrite is a strong word. So, let’s look at the paradigms involved here. If someone thinks that a hazard is something that is inherently dangerous like a flame, toxic chemical, etc. and you get them to look at a concrete bridge on the highway; and then ask, “Is that bridge a hazard?”, most of them will inspect the bridge, and if there’s nothing wrong with it, they’ll say no. “But what if you hit it at 60 mph (or 100 km/h)—on a motorbike?” Well, then it could kill you…
So, it isn’t just about the inherently dangerous hazards. It’s also about hazardous energy—which includes kinetic energy (see Figure 1). And in terms of potential for harm, this could be if something hits you (line-of-fire), or if you hit it or you move into it (eyes not on task, mind not on task, balance, traction or grip).
When you think about all of the forklifts and pieces of mobile equipment, or all the people riding bikes or driving cars, what tells the driver or the operator what they could be moving into other than their eyes and their minds?
Which means that whenever people are moving, eyes on task and mind on task become “primary” not secondary in terms of preventing incidents and accidental injuries. And in terms of inherently dangerous hazards like a toxic chemical or a sharp edge, unless you contact the hazard there won’t be an injury. However, you wouldn’t move into it if you could see it or you were thinking about it. So again, eyes and mind on task are very important. Or, to put it another way, eyes not on task and mind not on task are usually (almost always) contributing factors with these kinds of injuries as well. Although with inherently dangerous hazards it’s arguable that the guarding of the saw blade and containment of the chemical is just as important or more important.
However, since nobody is ever trying to get hurt, in almost every unintentional incident, one or two of the critical errors were also involved. For example: If a tradesman has just finished welding something and it is still red hot, the welder would not touch it with his bare hand if he was looking at the red hot metal. However, if he took his gloves off, and then turned without looking because somebody called him, then he could touch it by mistake. Or, if the metal had cooled down enough that it wasn’t red hot anymore he could touch it if he wasn’t thinking that it could still be very hot. The only other way he could contact the hot metal is if he lost his balance and—in an effort to regain his balance or stop himself from falling—his hand contacts the hot metal by mistake as a result of his reflex action.
When you think about all of the forklifts and pieces of mobile equipment, or all the people riding bikes or driving cars, what tells the driver or the operator what they could be moving into other than their eyes and their minds?
In total, there are four critical errors that by themselves or in combination are contributing factors in almost all incidents and accidental injuries. Two have already been mentioned: eyes not on task and mind not on task. One or both of these first two critical errors can cause someone to move into the line-of-fire or to lose their balance, traction or grip. Typically, it is one or more of the second two that actually put us into contact with the hazard or hazardous energy. So, it’s not just about the inherently dangerous hazards. It’s also about all the potentially hazardous energy – which includes kinetic energy – which means that movement is important, and that means eyes and mind on task are important. And what that means is that unless your friends, family and colleagues are different than most people, eyes not on task and mind not on task were involved in almost every one of their serious accidental injuries—whether they were at work, at home or on the road, or whether the hazards were electrical, thermal, chemical or mechanical (including gravity).
Furthermore, these two critical errors were also most likely involved—no matter what they were doing—whether that was welding, climbing a ladder, walking or running down stairs, cutting, chopping, sawing, driving or riding, cleaning or washing, etc. But that all makes perfect sense because we are never trying to get hurt anywhere, anytime, no matter what we’re doing. And it is certainly possible to get hurt on something like a staircase, when there’s nothing wrong with the staircase or no visible “hazard”, like a cord or a spill… So, when it comes to the question, “What’s more important?” it’s obvious that human error is hardly “unimportant” whether you have a well-managed safety system or not. But the “what’s more important?” question goes ever further. If we consider the “sunk costs” of engineering controls, PPE, etc. they don’t affect “top line” revenue. However, human error does, even if it’s just a simple mind not on task error that causes a sales rep to miss a lunch meeting.
What about quality? Does human error affect quality? Why do carpenters say, “Measure twice, cut once”? Answer: because it’s cheaper and faster than cutting twice (especially if you measure too short). And then there’s maintenance, finance, administration and HR. It’s hard to think of a job or a task where human error or inattention would not be a factor. So, if you could improve eyes on task and mind on task you would improve much more than safety, or the bottom line. You would also improve production, quality and customer relations (outside or inside customers). And that’s a big paradigm shift for a lot of people, especially the managers who think safety is a sunk cost. So… what’s more important?
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3 thoughts on “#1 – Hazards or Human Error?”
This is an incredibly powerful concept which strips bare the limitations of traditional safety management approaches (and BBS) – a big ah-ha moment!!
It is simply not possible to argue against this logic! The message comes across very powerful.
Traditional safety management has arguably its forces and serves the purpose of ensuring a reasonably safe working environment free of physical hazards – which is also needed – but it for sure has its limitations when dealing with human error.
In the workplace and to a similar extent at home or on the road, there are only 3 main sources of unexpected events: either the equipment does something unexpectedly, someone else does something unexpectedly or we do something unexpectedly.
This article explores the importance of incorporating human factors into all risk assessments. It also begins to explain the counter-intuitive nature of serious injury causation.
This article begins by explaining that what really causes the majority of serious injuries isn’t what we’ve been told. And then by reflecting (once again) on our own personal risk pyramid, the importance of mind on task is discussed.
#5 – Equilibrium: The Progression and Eventual Termination of Safety Judgement and Skill Development
What most people don’t realize is that the number of “defenseless moments” they experience is continuing to go up as they become more complacent over time.
#6- The State To Error Risk Pattern And The Concept Of Self-Triggering
In this episode when you think about all of injuries in the self-area (over 95%), and then think about the four critical errors: eyes not on task, mind not on task, moving into the line of fire and problems with balance,
#7 – The Neuroscience Behind the Critical Error Reduction Techniques
Although the neuroscience has only been possible since FMRI’s were around, or for about half as long as the critical error reduction techniques have been available, it does help to validate the techniques. However, the biggest benefit or the most important benefit the neuroscience really proves, is why the repetition of the concepts and discussing how the injury or close call could have been worse, is so important in terms of improving and strengthening the neural pathways which enables our sub-conscious mind to develop that instant sense of danger when we’re rushing, frustrated or fatigued (critical error reduction technique #2).
#8 – The Complacency Continuum And “When vs. What”
Knowing what actually causes the majority of serious injuries and fatalities is a good start, certainly much better than guessing or assuming that it’s due to a lack of management commitment. However, in order to prevent serious incidents and fatalities we need to know “when”. When will be most likely to make a critical error? This article explores the concept of Anticipating Error™ and provides practical tools for helping you and your employees to Rate Your State™ when in a situation where there is a high risk for making one or more critical errors that could cause a serious injury or expensive mistake.
#9- Critical Decisions – Part 1: Normal Risk vs. Making an Exception
Although there could be many reasons why people take deliberate risks, most people only operate in 2 modes. Either this is what they normally do (not wearing face shield) or today they are making an exception to what they normally do. It’s not really overly complicated. It’s also easy to see what states or combination of them could easily cause someone to “break their own rules”. However, this article will go even further and show how, by slightly extending the application, the same four critical error reduction techniques can be used to prevent making critical decisions that are compromised or negatively influenced by rushing, frustration, fatigue and complacency.
#10 – Critical Decision – Part 2: Deliberate Risk And Error
It’s interesting how most people avoid risk they can’t influence, like people who are afraid to fly but don’t worry about driving to the airport. People tend to underestimate the risk that depends on not making an error. So much so that they will deliberately do things that will take their mind off task, or—as with texting and driving—take their eyes and mind off task at the same time. This article explains the importance of trying to increase mind on task, and provides practical tips for how to do this when the amount of hazardous energy is high enough to cause serious injuries, but has become too common or too familiar like driving 60mph/100kph on highway or working around fork trucks in a manufacturing plant.
#11 – Improving Quality, Production Efficiency And Customer Relations
This article explains how often the four states are involved in all aspects of human error, apart from when people are learning or doing something new. This is another huge paradigm shift for most people. However, once they realize just how many mistakes they make, every day or every week due to the four states, it’s relatively easy to get them to use the same critical error reduction techniques along with other concepts or techniques like fail-safe, double-check, Anticipating Error™ and Rate Your State™ to minimize or prevent making big mistakes that could affect quality, production efficiency or that could cause significant problems with sales or customer relations.
This is an incredibly powerful concept which strips bare the limitations of traditional safety management approaches (and BBS) – a big ah-ha moment!!
Great insights that will forever change the way we see safety! 👏🏻👏🏻
It is simply not possible to argue against this logic! The message comes across very powerful.
Traditional safety management has arguably its forces and serves the purpose of ensuring a reasonably safe working environment free of physical hazards – which is also needed – but it for sure has its limitations when dealing with human error.