1. Human Factors Root Cause Analysis
Error (unintentional) or Violation (deliberate) Violations
(Breaking the Rules)
Errors
What Best describes the error
Do an unplanned action
e.g. use wrong object,
transpose numbers wrongly
Slip
Forget to carry out task
(often occur during
periods of waiting)
Lapse
These occur if the attention is diverted easily
Believed doing the
right thing
Knowledge based
• Experience
• Information or
understanding
Rule Based
• Expect to conform to rule
Mistake
Errors occur due to:
• Environment – noise, light, heat, distractions, etc
• Extreme task demands – high workload, monotonous tasks, disruptions
• Social or organisational factors – low numbers, conflicts, peer pressure
• Individual factors: training ,fatigue, illness, attitude, personal issues
(work/home), drugs
• Equipment – poor design, poor procedures
How Does this Best describe the violation?
Has Become the Normal
Way of Working
Routine
Violation
Looking to cut corners, often
due to:
• A perception that rules are
too restrictive
• Believe rules no longer
apply
• Lack of enforcement
• New starter believes it is
the normal way to work
Pressure of the job
Situational
Violation
Often due to a lack of:
• Time
• Numbers
• Right equipment
Human Factor Root Causes
1. Poor Organisational Change or
Transition Management
2. Inappropriate Staff levels and
Workload
3. Insufficient Training and
Competence
4. Fatigue (shift work and
overtime)
5. Poor Procedures (not just
SOPs)
6. Lack of Human Factors
consideration in risk
assessment and investigations
7. Poor Communication
8. Lack of Human Factor
considerations in design
9. Poor Organisational Culture
Exceptional
Violation
• Rare
• Knowledge of risk
• False belief benefit >
risk
Editor's Notes
HSE – top 10:
Organisational change and transition management
Popular in last twenty years due to downsizing
They result in overseeing all aspects of the other 9 issues so an increase is seen in each of them
Care must be taken that in Organisational change Human Factors are taken into account
Assessment against number 2-10 should help to provide this
Staffing levels and Workload
Budgetary Constraints and Downsizing have resulted in less staff and higher workload
Appropriate assessment must be made of the number of staff required to carry out a task
This must take into account HF issues to ensure that errors, mistakes and violations are not at risk of occurring
Training and Competence
Quote from the HSE: ‘Sites are good at training but not good at assuring competence’
Ensure training is:
High quality
Properly managed
Content is well chosen
Counting the hours training is not enough!
Fatigue from Shift work and Overtime
Effects of shift patterns and overtime now better understood
Shift patterns for quality-critical staff need to be designed to avoid fatigue
Effective policies and monitoring needed for overtime and shift swapping
Consider use of Fatigue Calculators
Procedures
Key element of compliance system
Need to be technically accurate, well written, usable and up to date
Think about ownership, the form of the procedure and the style
Try to use
Flow charts
Decisions tables or trees
Questions and diagrams
HF in risk assessment and investigations
During investigations ensure that Human Factors Root Causes are Considered
40% of Nuclear accidents have a HF root cause
When carrying out risk assessments :
Do not Introduce the potential for errors in your process
Do not allow your system fail due to error (make the system error tolerant)
Do not make your system too complex/hard to do/ time consuming that a violation will occur.
If these will occur the task should be redefined (where possible) or steps put in place to minimise the risk
Communications
What can go wrong?
Information that is :Missing, unnecessary, inaccurate, poor quality and not carried forward
High risk situations
During maintenance, during deviations, following absence from work, between experienced and non-experienced staff
In improving communications consider
Specify key information
Using communication aids
Repeat key info in different ways
Have sufficient shift handovers
Encourage the use of confirmation, clarification and repetition
Encourage face to face communication
Develop skills and set standards for communication
HF in Design
‘Ergonomics' – ensuring the fit between people and the things they use
Develop Ergonomics awareness in user reps and design staff
Develop HF checklists to be used during design and commissioning of equipment
Consider equipment and displays
Organisational Culture
Compliance culture is an important factor in achieving and maintaining good quality performance
Key factors include:
Open communication
Management commitment
Leadership
Availability of resources
Balance of delivery and quality.
Maintenance Error
As for all tasks
Identify if the task is error-tolerant or not subject to a violation being performed. If this is possible the task should where possible redefined or steps put in place to minimise the risk
