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.
In the last paradigm shift, “3 Sources of Unexpected Events”, we learned that there are three main sources: the equipment doing something unexpectedly, someone else doing something unexpectedly or you (me) doing something unexpectedly ourselves. We used a reliable database—what has actually happened to us. We built our own personal risk pyramids. This gave us more than just numbers. It also got us thinking about the source of the unexpected event in our own serious injuries.
The conclusion was that over 95% (97-99% in most cases), the unexpected event was in the “self-area”. So, for this next paradigm shift, let’s go back to that reliable database (what’s actually happened to you), and ask you to think about the most dangerous thing you’ve ever done. It could have been skydiving, scuba diving with sharks, driving over 100 mph (160 km/h), etc. But think of the instance, not just a general category like driving or riding your bike—more like when you were riding your bike down the steepest hill, going the fastest you’ve ever gone on your motorcycle or in your car…
Okay, now for the easy part: just think of your worst injury or your two worst injuries. And then, the last question: do you have a match? Does your most dangerous thing equal your worst injury? Does your second most dangerous thing equal your second worst injury? What about the third most dangerous thing, and so on.
If you’re like most people, chances are you don’t have a match. In other words, your worst injuries didn’t come from the most dangerous things you had ever done. (Note: With 100 people in the room, you normally only get one to three hands in the air for people with a match).
As you can imagine, this is another real eye opener for most employees. Especially those who took the traditional risk matrix as being valid-for granted. (Figure #1). Although it seems to make perfect, intuitive sense that people would get hurt when they were doing the most dangerous things, that isn’t what actually happened to over 95% of us.
An obvious explanation for this is that when you are doing something that you think is dangerous or extremely dangerous, chances are you’re paying attention or full attention (eyes and mind on task). How much does that change the risk? And what about the opposite: how much does risk change when your eyes are not on task and your mind is not on task?
So, what does this mean in terms of the old risk assessment matrix? Well, it means that if we want to prevent serious injuries and fatalities (the majority of them), we have to go beyond the obvious risks. We will need to look at another dimension of risk assessment, which is human error. How much does someone making a mistake, like not looking before they move, how much does that change the risk? And can we predict when and where someone will make a mistake that could cause serious harm?
Consider the following scenarios and the risk of a single vehicle collision:
1. A driver is going at excessive speed but is paying attention.
2. A driver is going at normal speed but is not paying attention (driving on auto-pilot).
Which scenario has more risk? If you had to bet, which one would you put the money on? Or, if given a chance, would you prefer not to bet?
Now, consider the second scenario, but in addition to driving at normal speed—on “auto-pilot”—the driver is also really, really tired… now, how much would you bet? So, we know that calculating the risk of inattention is difficult—not that anybody’s arguing that it’s unimportant—but it’s difficult. However, we do know this much: the risk of inattention goes up if someone is rushing, or going faster than they normally go, frustrated, fatigued or a little too complacent.
Note: in most cases it will be a combination of states: like fatigue and complacency that causes someone to fall asleep at the wheel.
Figure #2
So, the four states and their intensity are key components to calculating the probability of occurrence (x axis), and the critical errors like eyes not on task and mind not on task are the 3rd dimension (z axis). Although these two critical errors are not necessarily equal either—and definitely affect the probability of severity (y axis)—more on that next issue. (Figure #2)
But for now, the main argument or paradigm shift is that an accurate risk assessment is not just about the obvious or the intuitive risks. Think about it: if getting hurt was not counter-intuitive how many thousands of years ago do you think your ancestors would have quit getting hurt! Moreover, if we want to prevent the majority of serious injuries and fatalities we need to look beyond the obvious basics, and start to include human error and the potential for human error in all your risk assessments, otherwise, they could be misleading and create a false sense of security in situations when it’s not high voltage, high temperature, high speed, etc. and that would be the epitome of irony: that your risk assessment increased risk.
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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.
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 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.
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