Human error not a safety issue???

Quote from an article about the Maglev crash in Germany this month. "The crash has prompted a closer look at safety, even though the cause was probably human error."

What a strange thing to say. This seems to be the classic where people assume high technology and automation remove the opportunity for error and so human factors are no longer relevant. The reality usually is that error likelihood may be reduced but the potential consequences are higher and the errors are more complex in nature. Therefore, human factors is far more important.

Article here from the Economist on 28 September 2006.

Andy Brazier

Fire risk assessment

Attended talk yesterday given by Dai Roberts of North Wales Fire and Rescue service. About new fire regulations coming in on 1 October 2006.

Main point made was for any employer, it is their risk and they must manage it. Fire service will no longer give certificates or specific advice. The minimum requirement is to have completed a suitable and sufficient fire risk assessment and to have plans in place to address any significant findings.

The new regulations apply to nearly every type of building except domestic premises. In early days the priority will be 'high life risk' premises, which include pubs, hotels, community centres, hostels.

Fire services will audit risk assessments and premises. The is a concordat that requires them to act in a fair way. In practice this means they will give 5 weeks notice of an audit, unless they have reason to believe there is a problem (e.g. if there has been a fire or specific complaint).

Fire services will be responsible for fire safety of premises. HSE will maintain responsibility for process (i.e. the activities at the premises).

Andy Brazier

Maglev train crash

Several news items regarding the crash in Germany on 22 September 2006. Seems that the train was on a trial run and crashed into a maintenance truck that was on the tracks. The presence of the truck had been noted in a handwritten log by controllers, but automatic detection did not work.
The suggestion that human error was to blame is being made. This seems inevitable, at least a failure of communication between truck, controllers and train. Knowing this on its own won't really help us make it any safer.
Chancellor Angela Merkel is quoted as saying "At this point I don't see any connection with the technology. The technology is a very, very safe technology." People tend to think that technology and automation eliminate the possibility of human error. The reality is they change the opportunities, and often whilst the likelihood may be reduced the potential consequences are often much greater.

Articles from Reuters
and
Yahoo news

Andy Brazier

Calculated risks

Amanda Platell in Daily Mail on 23 September 2006, writing about the crash TopGear presenter had in a jet powered car.

She quote Hammond saying sometime in the past "I would only take calculated risks." She then goes on to say "well, somehow his calculation went disastrously wrong."

Why does having a crash mean that his calculations were wrong? Unless the risk was zero, there is always a possibility that something will go wrong and that some harm may result. Unfortunately no one seems to acknowledge this nowadays.

What a daft thing to write!

Article is online here.

Andy Brazier

Getting to grips with human error

Some very useful looking resources on the UK P&I clubs website

Link

At the bottom of the page there are links to a couple of PDF's that seem to sum up issues regarding error rather well.

I don't known anything about UK P&I club, but they are clearly in the maritime industry and I think they are something to do with insurance.

Andy Brazier

Sensible risk management

From BBC website on 22 August 2006

Link

A campaign has been launched to encourage people to stop worrying about "trivial" concerns over safety and concentrate on real risks. The Health and Safety Commission said unnecessary concerns over paperwork and the fear of being sued were being used to cancel school trips and outings.

Instead it is urging people to focus on risks that cause harm and suffering.

The HSC is concerned that too much concern over paperwork and bureaucracy will stifle learning and innovation.

Quote from Chair of the HSC Bill Callaghan:

"My message is that if you're using health and safety to stop everyday activities - get a life and let others get on with theirs."

Andy Brazier

ISO 14001

From a short talk given by Ollie Shaw of Standard Plus

Achieving ISO 14001 involves the following (year long) project
1. Initial review - current arrangements
2. Define improvement programme
3. Define controls - work instructions
4. Operate the system
5. Audit
6. Assessment

To determine the importance of environmental aspects you need to evaluate
1. The impact - land, sea, air, noisy, ugly, gas guzzler (expensive on resources)
2. Its significance - legislation, cost, interested parties

Whilst a company may measure performance in financial terms, it is important this is not presented to the ISO assessor who is interested in environmental measures. For example, saving electricity may save £X per year, it is better to describe in kW.

Andy Brazier

Drilling rig fatal accident - Morecambe Bay

Texas-based oil and gas multi-national Ensco has been ordered to pay fines and costs totalling £290,000 after the tragic death of a worker (Russell Bell aged 25) died after falling 100ft into the Irish Sea in Morecambe Bay from a gas exploration platform. According to an article published on 12 September 2006 on

Lancashire Evening Post website.

He was involved in derigging some hoses that had been used for cooling lifeboats whilst flaring was taking place. Judge Russel said "Tragically he was unable to hold on to the ladder he had stepped onto and fell to his death some 100ft into the sea". It was accepted that the company did have a "safety culture" in place and there was no question of them, "putting profits before safety".

Mr Bell should not have been on the ladder according to safety instructions but the company, said Judge Russell, should have put measures in place to deal with human error.

Health and Safety for beginners website provides some more information and photos. It seems the dead person was replacing stair treads. He was supposed to only have one missing at any time, but for some reason had removed two. The article implies that, whilst this was fully covered on the permit to work, enough may not have been done to explain the permit and discuss the job before starting.

Andy Brazier

Working time directive - rest breaks

EUobserver.com article 7 September 2006

The European Court of Justice (ECJ) ruled on Thursday (7 September) that the UK must change guidelines saying that employers "must make sure that workers can take their rest, but are not required to make sure they do take their rest." The requirement is that employers make sure employees take their breaks.

This includes 11 hours away from work in any day (between shifts) and break at work if present for more than 6 hours.

There are complaints from business that this interferes with flexibility. However, my observation is that there are too many people in safety critical roles not taking breaks, and this can only contribute to fatigue which has short and long term effects.

Andy Brazier

Fire risk assessment

There seems to be a lot of debate about fire risk assessment, which are part of the new fire regulations coming in on 1 October 2006.

There is a particularly good debate going on at the Fire Net Forum

http://www.fire.org.uk/punbb/upload/viewtopic.php?id=1073&p=1

Around page six there is a discussion about whether the man in the street understands descriptive or numerical estimates of risk. Is it better to say that a fire is likely or to say there is a 75% chance of a fire. People may well understand the numbers better but may assume it is based on a more scientific approach, when in most cases it is just someones 'gut feeling.'

There is a rather worrying debate on the IOSH forum

http://www.iosh.co.uk/index.cfm?go=discussion.view&forum=2&thread=20603

Some people on this one don't seem to know what a risk assessment is!

Andy Brazier

Driving coaching

Article titled 'Joined up thinking better for Drivers' on femalefirst.co.uk 6 September 2006.

Research by Brunnel University has shown that the coaching and practical on-road assessment and feedback providing by the Institute of Advanced Motorists improves people's driving ability, whilst others do not improve after passing their test, or even deteriorate.

Improvement is put down to having a greater awareness of other road users, road conditions, and infrastructure. But the greatest impact is the ability join these up so that drivers can achieve an overall understanding of potential hazards and the appropriate driver response.

They break the competence into knowledge of what was going on around them, skills applied to the driving tasks, and attitude towards driving.

Andy Brazier

Leading by example

Zoe Thomas writing Sunday Times 'Best Companies' supplement on 3 September 2006

Top tips for leading by example include:
1. Listen to your employees
2. Act on what staff tell you, or explain why you do not agree with their idea
3. Trust your workforce and delegate important jobs to them
4. Trust fellow senior employees
5. Formulate clear company values/principles
6. Live the company values yourself
7. Place the company first, not your own personal ambition
8. Keep meetings with other senior managers to a minimum
9. Communicate decisions arrived at such meetings to all staff
10. Make sure everyone in the company knows who is responsible for what

Best companies to work for

Article by Zoe Thomas in Sunday Times 'Best Companies' Supplement on 3 September 2006

Eight critical influences on the overall workplace experience are:
1. Leadership: how people feel about the head of the company and the most senior managers
2. Personal growth: to what extent people feel stretched by their job
3. My manager: people's feelings towards their day-to-day managers
4. My company: feelings about the company people work for as opposed to the people they work with
5. My team: people's feelings about their immediate colleagues
6. Wellbeing: how people feel about stress, pressure and the balance between their work and home life
7. Giving something back: how much companies are thought to put back into society and the community
8. Fair deal: how happy employees are with their pay and benefits

Apparently, success in these factors generates "employee engagement" which defines the quality and strength of relationship between the workforce and their organisation.

Andy Brazier

Problems with new technology

David Johnson article "Don't wince when the digital revolution behaves like a spoilt brat" in the Sunday Times on 3 September 2006

He describes the newest technology as being "like a wayward child that you want to embrace, even if it will keep spitting you in the eye." This is because companies are more interested in giving us headline-grabbing new features or a new look, without thinking how they will work in practice.

He quotes examples including the new Nokia 6233 mobile phone with a screen you can't read in daylight and the LG chocolate phone with a touch sensitive keypad that performs unwanted actions when your finger hovers over it. Also, rail company Southern introduced an electronic ticket machine that required users to wade through multiple pages and often rejected credit cards late in the sequence, causing huge queues.

Other complaints include website for booking tickets where you are never sure if the transaction has gone through successfully. Items with "known issues" such as a DAB radio that would not turn off or a VCR that could not record when first put on sale.

Also, it doesn't help that different manufacturers use different names for the same basic functions. The name even changes between different models from the same manufacturer.

Andy Brazier

Computer Science for Fun

I have been looking around the Computer Science for Fun website. Some really interesting games that introduce useful concepts about error, user interfaces etc. Well worth a look

CS4F Website

Andy Brazier

Everyday errors

Good article on the Computer Science For Fun website about research into pilot error. Includes a space invaders game that can be played on line that induces you to make errors to see if you avoid them.

http://www.dcs.qmul.ac.uk/cs4fn/humanerror/

Web article talks about every day errors that most of us make. The list includes

Forget your change in a shop or from a vending machine?
Forget to take the receipt?
Photocopy something then forget the original.
Forget to switch off the headlights of your car?
Forget to switch off the gas on the cooker.

People are naturally prone to make these errors because they all involve completing the thing you were trying to do: get a drink or chocolate, a photocopy, arrive at the place you were going to, cook the meal, etc. For all of these errors there was an extra thing you had to do after you had completed the main task ... and you forgot to do it. (take the change, take the receipt, switch off the headlights or the gas). Experiments have shown that these errors happen due to working memory overload combined with the structure of the task.

Early cash machines gave back the money first then the card. People regularly forgot their cards. Same error. Now, in Britain at least, the machines always give the card back first. People rarely forget their cards with the redesigned machines. Better design: human error disappears.

Andy Brazier

Back injuries

Very comprehensive article about back injuries, prevention and treatment by Josh Cable

http://www.occupationalhazards.com/articles/15578

"Of the 1.3 million reported lost-time injuries and illnesses in private industry in 2003, sprains and strains – most often involving the back – were far and away the leading type of injury in every major industry sector, accounting for 43 percent of the total lost-time cases, according to the Bureau of Labor Statistics (BLS)"

"While it's not easy to put a nationwide price tag on back injuries, the 2005 Liberty Mutual Workplace Safety Index found injuries caused by overexertion – defined as excessive lifting, pushing, pulling, holding, carrying or throwing an object, all of which are key ingredients of back injuries – cost employers $13.4 billion."

Maintaining the curve is key. It is suggested we unlearn proper use of a out bodies at a young age, around 4 or 5.

Motivating ergonomic behaviour

Article by Robert Pater presented June 2006 at ASSE's (American Society of Safety Engineers) annual Professional Development Conference. Summarised here

Many organisation have employed engineering solutions to improve ergonomics. They have been successful, but improvements have plateaued. Behaviours need to really change for further improvement.

Pater states that "leaders incite change by motivating receptivity and trial of new behaviors, transferring critical mental and physical skills and reinforcing improved performance – all with a goal of setting positive, safe default habits." He proposes a seven stage approach

1. Set and assess ergonomic-motivating objectives - realistic expectations
2. Identify barriers to ergonomic receptivity and behavioral change.
3. Energize all - move from just prevention to personal benefits of fitness
4. Spark involvement - simultaneous topdown/bottom-up "scissors" approach
5. Focus on home, as well as work
6. Build critical ergonomic skill sets, both mental and physical
7. Make it (self) reinforcing - publicise plans and success, get everyone talking about it.

To achieve involvement managers can help select the leading ergonomic indicators they deem valuable. Supervisors are involved in setting the timing for and reinforcing action changes. Some employees might be trained to become "peer catalysts," who are agents of ergonomic behavioral change. And all workers can select and monitor personal ergonomic objectives.

Pater lists skills sets that can be taught as
seeing your own level of accepted risk;
directing attention at will;
recalling policies/procedures/techniques;
understanding and applying underlying ergonomic principles;
maximizing leverage to maximize effective strength;
heightening balance;
improving eye-hand coordination;
boosting flexibility/range of motion;
reducing fatigue;
controlling breathing;
effective preparation and recovery methods.

Andy Brazier