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HEALTH AND SAFETY AT WORK MAGAZINE

CAPTURING THE HUMAN FACTOR

By Mike Everley

"We seem to have passed the era where the need

was for further engineering safeguards in particularly

hazardous industries. What we now need is to

capture the human factor"

John Rimington - ex Director General HSE

Background

Safety, in recent years, has focused on physical and engineering controls and upon safe working
procedures. It’s hardly surprising therefore that, after designing safe equipment and devising safe
systems of work, the focus should now be turned onto that other variable- the human being. Greater
improvement in safety performances may rest upon a greater understanding of employees and their
attitudes and behaviour in the workplace.

Understanding employee behaviour is also a central requirement in a self-regulatory system, where the
controls and influences are more likely to come from within the organisation than from external bodies
such as the Health and Safety Executive. Although external bodies such as insurance companies can
exert considerable financial pressure on self-regulatory organisations to develop a human factors
approach to health and safety. Such an approach can include the screening-out of employees who
present an above-average risk. Furthermore, there has been a perceivable shift towards greater individual
responsibility for the health and safety of ourselves and others.

Safety Practitioners have often relied upon the safe place – safe person strategy to direct their thinking
and such a strategy often underpins both risk assessment techniques and accident causation models as
the following diagram illustrates.

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The term "human factors" is often used to cover a range of issues. These include the perceptual, mental
and physical capabilities of people and the interactions of individuals with their jobs and working
environments, the influence of equipment and systems design on human performance and, above all, the
organisational characteristics which influence safety-related behaviour at work. This safety-related
behaviour forms the base of the accident triangle (whichever variant of the triangle is used).

Put simply, there is a ratio between the near misses at the base of the accident triangle and the major
injuries at the top (the exact ratio varying according to the variant of the technique adopted). It is often
only luck which determines which incident will be a near miss and which will be more serious.
However, it is the behaviour patterns of the individuals involved which give rise to both the near misses

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and the more serious accidents. Therefore, near misses are also preventative opportunities for the Safety
Practitioner as they indicated which behaviour patterns need to be changed before luck runs out and a
serious accident occurs.

However, it is important not to jump to the conclusion that incorrect behaviour patterns on behalf of
individual employees equates directly with fault. Often the behaviour patterns are a result of
organisational failures or pressures to which individual employees are merely responding. Organisations
wishing to correct inappropriate behaviour patterns need to consider every rule and procedures, in all
operational and emergency situations, and to replace those which cannot be followed with new rules and
procedures that can be followed. Employees will then need to be trained in the new rules and procedures
and monitoring systems will need to be introduced in order to ensure that they are, in fact, being
followed. This approach requires a fairly heavy resource commitment on behalf of the organisation.

It is within this context that the Health and Safety Executive’s publication Reducing Error and
Influencing Behaviour (HSG48) needs to be considered.

HSG48

Reducing Error and Influencing Behaviour is in fact a substantial revision of the previous publication
Human Factors in Industrial Safety and it is good to note that the Health and Safety Executive have
noted the perceptual failings with regard to the previous publication – notably the fact that the term
industrial limited the scope of the audience despite the fact that human factors apply to all workplaces
(this misperception was reinforced by the use of a heavy industrial scene on the front cover and the
selection of examples mainly relating to heavy industry). The new publication is clearly directed at all
workplaces and all work activities (as the front cover, title and selected examples clearly reinforce).

According to Reducing Error and Influencing Behaviour: "Human factors refer to environmental,
organisational and job factors, and human and individual characteristics which influence behaviour at
work in a way which can affect health and safety". In other words the three crucial elements of job,
individual and organisation need to be carefully considered.

Element Detail

Job Factors Requires tasks to be designed in a way

that takes into account ergonomic
principles and recognises strengths and
limitations in human performance.
Matching the job to the person requires
consideration of both a physical and a
mental match. It is the mismatch
between job requirements and individual
capabilities that provides the opportunity
for human error. Hence the need to
match the employee’s capabilities to the
task they are being asked to perform as
required by the Management of Health
and Safety at Work Regulations 1999.

Individual Factors Individual characteristics such as

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personal attitudes, skills, habits and

personalities can be strengths or
weaknesses depending upon task
demands. Certain individual
characteristics, such as personality, are
fixed, whereas other characteristics, such
as skills and attitudes can be modified or
enhanced.

Organisational Factors Organisational factors have the greatest

influence upon individual and group
behaviour. The organisational culture,
for example, needs to promote employee
involvement and commitment at all
levels and emphasis that deviation from
established health and safety standards is
not acceptable.

In order to begin to develop a fully-fledged human factors strategy, the above factors should be
considered during risk assessment, accident investigation, design and procurement as well as in day-to-
day operations.

The key objective of the publication is to move away from the mistaken notion that accidents and
incidents are the result of human error by the worker in the front line. "Attributing incidents to human
error has often been seen as a sufficient explanation in itself and something which is beyond the control
of managers. This view is no longer acceptable to society as a whole. Organisations must recognise that
they need to consider human factors as a distinct element which must be recognised, assessed and
managed effectively in order to control risks".

With regard to the three main factors, the following causes are often related to human failures in
accidents:

Job Factors

Illogical design of equipment, instruments.

Constant disturbances and interruptions.

Missing or unclear instructions.

Poorly maintained equipment.

High workload.

Noisy and unpleasant working conditions.

Individual Factors

Low skill and competence levels.

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Tired staff.

Bored or disheartened staff.

Individual medical problems.

Organisational Factors

Poor work planning, leading to high work pressure.

Lack of safety systems and barriers.

Inadequate responses to previous incidents.

Management based upon one-way communications.

Deficient co-ordination and responsibilities.

Poor management of health and safety.

Poor health and safety culture.

If the above are common causes of human failures, the failures themselves can be categorised into
various types involving errors and violations. The following diagram illustrates this point:

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The above model operates with the notion that all human failures can be categorises as either human
error or violations depending on whether or not intention was involved with the failure. A human error
being an action or decision which was not intended, but which involved a deviation from an accepted

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standard and which led to an undesirable outcome. Errors can be sub-divided into slips, lapses and
mistakes.

Slip Lapse Mistakes

Failures in carrying out Forgetting to carry out an Where we do the wrong

the actions of a task. In
other words "actions not
as planned". These might
include: Performing an
action too soon or too
late, Omitting a step or
series of steps from a task,
Carrying out an action
with too little or too much
strength, Performing the
action in the wrong
direction, Doing the right
thing but with regard to
the wrong object,
Carrying out the wrong
check but on the right
object.
action, to lose our place in thing believing it to be
a task or to forget what right. The failure involves
we had intended to do. our mental processes
Often linked to which control how we
interruptions and plan, assess information,
distractions. A simple make intentions and judge
checklist to follow can consequences. Rule-Based
help to reduce the Mistakes occur when our
likelihood of lapses behaviour is based upon
occurring. remembered rules or
procedures. Knowledge-
Based Mistakes are often
related to incomplete
information being
available.

Errors are more likely to occur where there are: Work environment stressors, Extreme task demands,
Social and organisational stressors, Individual stressors, Equipment stressors. Risk assessments should
therefore identify where such factors are present and assess the likelihood of errors taking place and
their consequences. Error control and reduction should take into account the need: To address the
conditions and to reduce the stressors, To design plant and equipment in order to either prevent slips or
lapses occurring or to increase the chances of detecting and correcting such errors, To ensure that
arrangements for training are effective, To design jobs to avoid the need for tasks which involve
complex decisions, diagnoses or calculations, To provide proper supervision, To check that job aids
such as procedures are clear, concise, available, up-to-date and accepted, To monitor that the measures
taken to reduce error are effective.

Whereas, a violation is a deliberate deviation from a rule or procedure. Most violations are motivated by
a desire to carry out the job despite prevailing constraints and very rarely are they motivated by wilful
acts of sabotage or vandalism. Violations can be sub-divided into routine, situational and exceptional.

Routine Situational Exceptional

Breaking rules or procedures
has become a normal way of
working within the work group
due to: The desire to cut
corners, The perception that the
rules are too restrictive, The
belief that the rules no longer
Breaking the rules is These rarely happen and only
due to pressures when something has gone wrong.
from the job, such To solve a problem employees
as: Time pressure, believe that a rule has to be
Insufficient staff for broken. It is falsely believed that
the workload, The the benefits outweigh the risks.
right equipment not Means of reducing such violations

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apply, Lack of enforcement of being available, could include: Training for

the rules, New workers not Extreme weather dealing with abnormal situations,
realising that routine violations conditions. Risk Risk assessments to take into
are taking place. Means of assessments should account such violations,
reducing such violations can help identify the Reduction of time pressures on
include: Routine monitoring, potential for such staff to act quickly in novel
Removal of unnecessary rules, violations as will situations.
Ensuring rules are relevant and good two-way
practical, Explaining the communications.
reasons for the rules, Improved
design to reduce the likelihood
of cutting corners, Involvement
of the workforce in drawing-up
the rules.

Developing a Strategy

HSG48 provides a powerful model showing the type of human errors and violations that can be
predicted from consideration of organisational, job and individual factors. Such a model can be used
both in risk assessments and accident investigations in order to suggest the control measures required to
prevent either an occurrence or a re-occurrence. The HSE Contract Research Report 175/1998
Individual differences in accident liability: A review provides an integrated model of accident liability
which can be utilised in relation to the model provided by HSG48.

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According to the Contract Research Report: " In terms of personality, the evidence presented in this
review suggests that extroversion and neuroticism are linked to increased accident vulnerability, but
does not suggest why this should be so. It is plausible that while neuroticism may be associated with

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accidents via an increased vulnerability to stress, extroversion may increase an individual’s willingness
to take risks. The model of accident liability attempts to integrate the findings of research into individual
differences in accident liability with more recent research into the various forms of human failure and
their role in accident causation. The model offered also attempts to link psychological, organisational
and behavioural factors together in the accident-producing nexus".

Job analysis is a useful technique allowing for the identification of important behavioural and
performance qualities and for the matching of individuals to jobs. However, it should always be
remembered that the personality characteristics that give rise to safe performance in one situation may
prove detrimental in another situation. For example; a rigid approach to rules and procedures may be
required in most instances, but a more flexible approach be required in an emergency situation. Such
factors need to be considered when risk assessments are performed in relation to normal operations and
emergencies.

Where the safety culture is clear and positive, group pressure can even influence an unstable extrovert
not to take risks. However; where the culture is ambivalent, and linked to performance targets and
deadlines, the message may become that short-cuts are acceptable in order to achieve targets.

HSG48 provides the following useful checklist of questions which organisations can adopt when
developing a strategy based upon the control of organisational, job and individual factors which can lead
to human failings:

The Job

Have you:

Identified and analysed critical tasks?

Evaluated the employee’s decision-making needs?

Evaluated the optimum balance between human and automatic systems?

Applied ergonomic principles to the design of equipment displays including

displays of plant and process information, control devices and panel layouts?

Thought about the design and presentation of procedures and instructions?

Considered available guidance for the design and control of the working
environment including the workspace, access for maintenance, lighting, noise
and thermal conditions?

Provided the correct tools and equipment?

Scheduled work patterns and shift organisation to minimise impact on health

and safety?

Considered how to achieve efficient communications and shift handover?

The Individual

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Have you:

Drawn up job specifications looking at age, physique, skill, qualifications,

experience, aptitude, knowledge, intelligence and personality?

Matched skills and aptitudes to job requirements?

Set up personnel selection policies and procedures to select appropriate

individuals?

Implemented an effective training system?

Considered the needs of special groups of employees?

Set up monitoring of personal performance on safety for safety critical staff?

Provided fitness for work and health surveillance where this is needed?

Provided counselling and support for ill health or stress?

The Organisation

Do you have:

An effective health and safety management system?

A positive safety climate and culture?

Arrangements for the setting and monitoring of standards?

Adequate supervision?

Effective incident reporting and analysis?

Learning from experience?

Clearly visible health and safety leadership?

Suitable team structures?

Efficient communication systems and practices?

Adequate staffing levels?

Suitable work patterns?

References

 Reducing Error and Influencing Behaviour. HSG48. HSE Books. £11.50.

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 Individual Differences in Accident Liability: A Review. Contract Research Report 175/1998.

University of Manchester Department of Psychology. HSE Books. £20.00.

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