Mary Clarke offers guidance on handling human error in high risk industries.
A key problem shared by all these industries is that mitigating against the risks of human error is notoriously difficult. Photo credit: Fotolia
All employees have the potential to make mistakes at work – regardless of how much training they have received. Yet in industries such as aviation, healthcare or rail, where safety standards are critical, the consequences of mistakes or human errors can be devastating.
To understand the impact of human error at work we don’t have to look very far.
Incidences of human error happen every day. In fact it has been estimated that 90 per cent of all workplace accidents have human error as a cause1 and the results can range from mere inconvenience to catastrophic. As shown, in cases such as the Bavarian train crash, human error can have far reaching consequences, and similarly medical misdiagnosis or incorrect dosage of medicine can have fatal results.
Currently, the subject of human error in the workplace is being debated widely in relation to the NHS. In 2015, Health Secretary Jeremy Hunt ordered an annual review into avoidable hospital deaths after it was reported that more than 1,000 patients a year die needlessly in hospitals.
Hunt said that the key to avoiding deaths is “changing behaviour and the way everyone works in the NHS”. He held up the aviation industry as an example of best practice – an industry where improvements in safety standards, staff attitudes and behaviour have resulted in global deaths falling from 2,000 to 500 a year.
A key problem shared by all these industries is that mitigating against the risks of human error is notoriously difficult. This is an area we have been helping companies address for nearly 20 years.
It is important when working with companies in high risk and regulated industries such as rail, utilities, banking and health and social care, to help them mitigate the risks of human error.
The best way to do this is by providing people-centred data to evidence compliance and identify any workforce skills, knowledge or confidence gaps that might impact a company’s performance or pose a potential risk to the company.
As human behaviour is a critical component of health and safety, having a better understanding of how front line employees behave when performing their job can help companies minimise risk, improve safety standards and ensure regulatory compliance.
Blaming human error
The Health and Safety Executive describes human error as an action or decision which was not intended. It claims that human error is normal and predictable, and it can be identified and managed.
Yet there is no easy way to protect a company from errors made by people. Take the Bavarian crash; why would a seemingly qualified Area Controller decide to open the track to two trains on a collision course only to notify both drivers afterwards? The Chief Prosecutor Wolfgang Giese said: “if he had complied with the rules…there would have been no collision”. While this seems slightly obvious it does raise the question why he didn’t follow the rules on that particular day when surely he must have known them?
When audits and investigations take place, it may transpire that the Controller took (and passed) all the right training, understood the correct processes that needed following and was an experienced and good employee. So why did things go wrong?
Most large companies, particularly those in high risk and highly regulated industries, invest millions if not billions of pounds embedding systems, technology and processes to mitigate risk, uphold and improve safety standards and efficiency. Yet, mistakes still happen and the root cause is often complex.
Identifying people risk
James Reason, Professor of Psychology at Manchester University, an expert on the role of human error in accident causation, says that the human error problem can be viewed in two ways.
Firstly, there is the person approach, which focuses on errors of individuals, blaming them for forgetfulness, inattention or moral weakness.
Alternatively there is the system approach which recognises that humans are fallible and errors are to be expected, even in the best companies. Preventing workplace accidents using this approach is based on the assumption you can’t change the human condition only the conditions under which the employee works.
Reason explains this using his ‘Swiss Cheese Model’ theory4. He says that 99.9 per cent of the time a company’s systems, processes and people will align and work together with no issues, despite small gaps in some places. However, when holes and gaps in different layers shift and align, everything can change in an instant.
One of the problems is that while most people want to do their best for their company, some have always navigated around standard procedures, processes, and best practice. In some cases they may have been told to side step a process by their manager or a more experienced colleague because it’s ‘quicker’, or ‘the way we’ve always done it.’
Such process tweaks can be very effective, but when they aren’t embedded effectively, they can, and do, expose companies on a mammoth scale. This exposes a company to People Risk.
When risk results in incidents and accidents companies resolve to do things differently. They pledge to review their processes and invest in more training. However, if the process or the training didn’t cause the accident, such initiatives are bound to be fruitless.
Why would a new process work if the old one wasn’t followed? How would more training benefit people who didn’t understand or apply their previous training? How will things be different in the future?
Experience in working in both the private and public sectors, shows us that around 30 per cent of individuals will misunderstand at least one aspect of their job. This could be a simple policy or procedure or a knowledge gap about critical areas of their role.
Most companies are in the dark about where their skills gaps lie, and consequently they are unaware they might be exposed to major risk.
Efficiency and culture can dramatically improve in organisations that have accurate, up to date data about people’s understanding, capability and confidence at work. If managers can see at a glance people’s strengths, their skills and also where knowledge and understanding gaps are, and the likely risks stemming from that, they are able to make strategic, informed decisions about how best to address them and how to develop their talent and improve performance.
But to mitigate against people risk companies first need to understand the root causes of behaviour and why incidents or misunderstandings happen – training and processes alone can’t do this.
Using situational judgment assessments to identify what people understand and how confident they are in their knowledge will show how they are likely to act in a real situation. For example if someone has high understanding in how to apply that knowledge, but lacks confidence to apply it, they might not use their knowledge in the right way under pressure, which is a huge risk.
What’s more dangerous, is someone who is highly confident but lacking in knowledge – they could be making disastrous decisions and mistakes that could put their organisation and their colleagues at major risk.
These assessments flag up potential risks and also provide managers with the people-centred data and analytics they need to take action. This insight also means that training can be targeted specifically to people’s needs. Companies can then avoid ‘sheep dipping’ everyone with the same ‘solutions’ and give people the interventions they need to develop their skills and improve their performance quickly.
Perhaps if this approach had been used by the Bavarian rail organisation this accident could have been avoided. With greater insight into the Area Controller’s specific development needs, his company could have given him tailored support and interventions to improve his performance – actions which may have pre-empted the catastrophe.
By providing organisations, who rely heavily on their people within high risk industries, with real time data about their people’s capability and their confidence delivering against required competencies, we can give them a global view of the understanding, capability and confidence of relevant teams and individuals. This enables them to identify potential areas of risk and take action to mitigate the risks before problems or accidents occur.
While we may never know exactly the root cause of some accidents at work, we do know that having access to people-centred analytics provides companies with a lens on their workforce – insight that enables strategic people-based decisions to be made to uphold safety standards, getting the most out of your existing investments in training and L&D, ensuring regulatory compliance and reducing the exposure to people risk.
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