Genuine errors that kill

Good post on NHS Blog Doctor. Discusses how we should deal with errors that have catastrophic consequences when someone does something quite normal. In this case the example is loosing control because of sneezing when either driving a car or a surgeon operating. The trouble is if someone dies because of someone else's error, the general public expect someone to be punished. Where someone is negligent or reckless (i.e. driving or operating drunk) this is quite clear-cut. But punishing someone for sneezing does not seem right.

A news article on a similar theme was on BBC website 7 November 2006 nurse gives baby morphine overdose.

In this case the nurse gave morphine meant for another baby when she thought she was giving human albumin solution. She was an experienced nurse and there seems to be no explanation for why she made the error. However, she was sacked and has now been found guilty of misconduct.

European power outage

Parts of Germany, France, Belgium, Spain, Portugal, Croatia and Italy were blacked out on 5 November 2006 when German power controllers switched off a cable that left some areas lacking power and others overloaded.

Good article about it on BBC website

It is interesting that inter-connecting national grids intends to secure supply. However, it adds complexity which can contribute to failures. This seems to be the result of new technology. The likelihood of failures are reduced but there consequences when they happen are often much greater.

Andy Brazier

Fire risks

There is a phenomenal amount of information available regarding fire at the following website.

I think it refers to the old regulations (i.e. before 1 October 2006) hence is in archive, but most will still be useful guidance.

Andy Brazier

Fatigue & alertness testing

A company in US (Bowles Langley Technology) has developed online tools that people can use to test their alertness. Aim is to allow people to test themselves to check if they are safe to work or drive home. You can try a demo on their website

Andy Brazier

Chronic fatigue after long working hours

October 2002 Mark Fiebig was killed when he fell asleep at the wheel of his car driving home from work. His employer has recently been found guilty of breaching health and safety laws and fined £30k + £24k costs as it was felt they had failed to monitor work hours closely enough.

This is interesting because the accident happened outside work hours. Admittedly the hours being worked were way in excess of what most would do, with it being reported that he had worked 17 hour shifts for four consecutive days. But it is a point I have raised with clients in the past, especially following night shifts. I have tried to encourage them to consider what they would do if someone said they felt really tired. Would they drive the employee home to make sure he got there safely?

The case is reported in a number of places including

Norwich Union

Cambridge evening news

TUC

The problems with behavioural safety

I have just found this article by Nancy Lessin published at hazards.org

Problems identified in this paper include:

* Focusing on worker behaviour tends to mean root causes of problems are not looked at closely enough. Production pressure is quoted as a common reason why employees do not behave as safely as they should;
* There is a tendency to place the burden of prevention on the worker, rather than developing technical solutions;
* Everyone makes mistakes, is at some time careless, complacent, overconfident, and stubborn. At times each of us becomes distracted, inattentive, bored and fatigued. BS seems to suggest this should not be the case, and that if people are more careful mistakes will not happen.
* BS tends to mean that any individual acting unsafely is subject to 'inquisitions.' This is not pleasant, so the result is incidents don't get reported.
* BS programmes can be used by management to justify actions that unions have identified in the past, and thus undermining the union.
* A 'systems approach' that emphasizes the identification and elimination of root causes of workplace injuries and illnesses: workplace health and safety hazards would be far more effective.

The paper quotes some examples of where unions and workers have fought back against BS. They include:
* Engaging in a campaign that includes educating and involving the membership, identifying allies, identifying leverage and employing escalating tactics.
* Workers all wearing anti-behavioural safety buttons (badges);
* Placing fluorescent stickers on hazards in the workplace to bring a focus back to hazards rather than workers' "unsafe behaviours";
* Making a sign for the union bulletin board that reads "It has been x days since we asked management to correct [a particular hazard] and they have still not fixed it" (and keeping the count going each day);
* Threatening to call OSHA in to inspect the workplace.
* The United Steelworkers of America developed buttons (badges) for locals going through such campaigns that have a large BS in the center, with a line drawn through it, and the words "Eliminate Hazards - Don't Blame Workers" around the outside.

I certainly don't agree with everything in this paper or the way the message is put over. However, I do also share some of the concerns and am convinced that a systems approach to improved health and safety would be more effective and likely to address process as well as personal safety, as well as health.

Andy Brazier

Safety last

Article in the Guardian by David Brindle and Paul Lewis on 18 October 2006 link

Provide a summary of the recent debate about society becoming more risk averse. Includes some examples. The problem is, what is the solution?

Andy Brazier

Controlling risk associated with violence

An excellent set of responses to a question posted on an IOSH forum to a question related to protecting doctors from violent patients. Not much for me to say. I just want to record the link here for future reference.

Link

Driver warning system

Article at CBC published 17 October 2006.

Ford Motor Co. testing a number of different systems that warn drivers when they stray off the lane on a road. Researchers studied drivers who had not slept for 23 hours and had each of the participants drive for three hours in a simulator.

Found that all systems were effective at improving reaction time, implying they would reduce likelihood of accidents. However, I wonder how much such devices will affect driver behaviour. Will people pay less attention when driving because they know there is a device that will warn them that they are straying. Will people drive for longer without a break or be less concerned about driving when they haven't slept?

Andy Brazier

Working under fire

Report by Robert Jaques 17 October 2006 published here

Military student medic were required to perform a thoracostomy (insertion of a tube into the chest cavity to permit fluid to drain) under virtual reality battle conditions.

Interesting findings
* The students' completion times showed that they could perform the surgery efficiently, but that the quality of their work suffered.
* Those who performed the procedure faster were more susceptible to the virtual sniper fire.
* The stress created by the simulated environment may have caused some students to engage in inappropriate and dangerous behaviour that would be likely to result in their being killed in a real combat situation.

Not sure how this would translate into a business setting, but I can imagine that during a major incident people are likely to act differently. We rarely get the chance to give our staff the opportunity to see what it will be like, and have no real idea of how they will react.

Andy Brazier

Employers not liable for unforseeable events

The HSE has recently lost a case at the court of appeal regarding a case where two employees of Hatton Traffic Management (HTM) died when taking part in road improvements on the A66 near Scotch Corner.

According to this website "HTM were providing traffic management services for contractors (L) who were resurfacing the A66. There were contraflow works, lit at each end by HTM’s mobile telescopic towers which were 9.1 metres tall. 20,000 volt electricity cables passed overhead, dipping to 7.5 metres above the ground. HTM had two employees on site, C and D, who took their day to day instructions from L. C and D were told to move one of the towers. They did not lower the tower under the cables (contrary, said HTM, to their training and to instructions on the tower) and the inevitable happened, with fatal consequences for both employees."

HTM were charged with failing to discharge their duty under s.2(1) of the Health and Safety at Work Act 1974, namely failing to ensure, so far as was reasonably practicable, the health, safety and welfare at work of all its employees. At a preparatory hearing, the judge ruled in favour of HTM on both points. The prosecution’s appeal was unsuccessful.

The HSE took it to appeal and lost. According to this website The implication is that this ruling demonstrates that "Employers cannot be found negligent on health and safety grounds when employees are acting outside their remit."

According to another website HTM's lawyer said after the case "If this argument had been upheld by the COA, Groch believes, it would have effectively removed of any real defence available to employers in the area of risk management. Insurance premiums would have also beeen affected as insurance companies would take action to protect themselves against substantial claims. Another disturbing implication would be that some employers may question the need to invest heavily in health and safety provisions if, in reality, they have no effective defence against criminal prosecution."

But this is unlikely to be the end of the case. HSE will probably take it to the House of Lords, and it does seem there is plenty to debate. I personally find it hard to say that with high voltage cable nearby that it was not foreseeable that workers may forget to lower the lights before moving them. Also, we all know people take shortcuts and we should consider this in our risk assessments.

A spokesman from Norwich Union made the following comments at this website. "In this case it seems that HTM argued they had taken all reasonably practicable steps to ensure the safety of the employees and had provided training and instruction, as required by law. But, they argued the sequence of events that occurred was not foreseeable.

"Some might consider this somewhat disingenuous, despite the ruling. If there is a shortcut - that will save a bit of time and perhaps enable an early tea break, a chance to have a few minutes in the cab out of the rain - then is it not the case that employees will find it?"

Andy Brazier

Human error caused Cyprus air crash

Reuters website 10 October 2006.

Crash in August 2005. The plane on a Larnaca-Prague flight flew on autopilot for two hours, its pilots slumped over the controls, before running out of fuel and ramming into a Greek hillside killing all 121 people on board.

The report blamed deficient technical checks on the ground, failure by the pilots to pick up on compression warnings and a series of other mistakes for the Cypriot Helios Airways Boeing 737-300 crash.

The compression system regulates the oxygen supply, which decreased as the aircraft gained altitude and rendered the pilots and passengers unconscious.

BBC webstite added more. Including:

* Pilots misread instruments regulating cabin pressure and misinterpreted a warning signal.
* Maintenance officials on the ground left pressure controls on an incorrect setting.
* Plane's manufacturers Boeing took "ineffective" measures in response to previous pressurisation incidents in the particular type of aircraft.
* Airline came in for criticism for "deficiencies" in its organisation
* The Cypriot regulatory authority was accused of "inadequate execution of its safety oversight responsibilities"

Andy Brazier

Eye strain from computer use

Article by Darryl E. Owens published 10 October 2006 on the Orlando Sentinal

Studies haven't found that long-term computer use produces permanent damage But some people do suffer from burning, watery, or dry eyes, or blurred or double vision during or after use.

There is no evidence that this is caused by radiation from the screen. However, the main causes appear to be decreased blinking during computer use and wearing improper or outdated eyeglass prescriptions.

Coloured tints and filters are not the solution. Instead properly adjust your office chair or positioning your computer monitor so that it is 20 to 25 inches from your eyes and slightly below eye level (a screen that is too high or too low will be hard for your eyes to work together). Also, adjust brightness and contrast.

Andy Brazier

The war on error

Article by David Learmount published 10 October 2006 on Flight website

Talks about a course titled 'Safety Stand-down' for experienced pilots run in US. Claims that the course "takes fully trained pilots well above and beyond what an advanced conventional or recurrent flying training programme provides. It challenges preconceptions, stimulates questions, and presents a pilot with a mirror in which his/her latent professional and personal vulnerabilities become fully visible. More than that, it renews a pilot’s respect for the multiple disciplines it takes to be a really good aviator."

Quotes Bob Agostino (Bombardier Business Aircraft director of operations): “Development of the human half of the man-machine equation has not kept pace with the technology developments in either formal training programmes nor in regulatory development.”

Also Dr Tony Kern (senior partner in Convergent Knowledge Solutions): "The challenge of human error will never be remedied by any traditional safety programme. Personal error must be slowly untangled in a private battle within each individual.”

Finally, researcher from University of Manchester: “The study of human error has grown dramatically in the last 20 years. We know why people make errors and how to prevent 90% of them, but no-one seems to care.”

Andy Brazier

Indian Air Force

According to article from Reuters on 5 October 2006 available here

"Out of nearly 800 MiG-21s that India's air force has acquired since 1963, 330 have crashed, mostly due to human error, according to official figures."

The Indian Air Force are buying new trainer jets to try and improve then safety record.

Andy Brazier

IT reliability

Article by Borris Sadacca on 3 October 2006 available here

Mostly concerned with datacentres, and the reliance on reliable equipment and reliable power supply including Uninterruptible Power Supply (UPS). "It is clear that to achieve high availability in the datacentre, IT directors need to look not only at the applications and server infrastructure and service level agreements associated with the IT, but also at the non-IT infrastructure - the mech­anical, electrical and plumbing systems that keep the datacentre operational."

It points out that systems designed to be highly reliable are often brought down by human error. Examples quoted include:
* Staff may be needed to work after hours and are tired.
* A common problem is when maintenance staff do not follow procedures step by step, which happens especially with well-versed personnel.
* Systems components are replaced even though there are no signs of wear or failure. This creates an opportunity for inserting other failures.
* Invasive checks that require the removal of other components can introduce problems.

"So while technology and multiple levels of redundancy can limit the effect of failure, much of what keeps a datacentre going is down to the people. Many problems can be avoided simply by operating a two-person maintenance team."

Andy Brazier

Shift work

Article written by George Brogmus and Wayne Maynard 4 October 2006
here

Findings of a recently published Liberty Mutual Research Institute study modeling the impact of the components of long work hours on injuries and accidents:

* Work-related injuries increased 15.2 percent on afternoon shifts and 27.9 percent on the night shift relative to the morning shift.
* Injury risk increases nearly linearly after the eighth hour of a shift, with risk increasing 13 percent on a 10-hour shift and almost 30 percent on a 12-hour shift.
* As consecutive shifts increase, injury risk also increases, but at a higher rate for night shifts than for day shifts.
* Average risk for injury is 36 percent higher on the last night of a four-consecutive-night shift. Risk increases incrementally over each night on the job: 6 percent higher on the second night, 17 percent higher on the third night – culminating at 36 percent on the fourth night.
* Injury risk is 2 percent higher on the second morning/day shift, 7 percent higher on the third day and 17 percent higher on the fourth day than it is on the first shift.
* Injury risk also increases as time between breaks increases. The last 30 minutes of a 2-hour work period has twice the risk of injury as the 30 minutes immediately after the break.

Advice to minimise problems includes:
* Evaluate the combined effect of work scheduling factors rather than to just limit total work hours (i.e. time of day, breaks on shift).
* Establish maximum limits for days and nights worked per week, including overtime. Whenever possible, favor day/morning shifts over afternoon or night shifts.
* Consider adding hours to existing shifts or add an additional day of work to the project, and limit work to five or six consecutive shifts.
* Provide for frequent rest breaks. Hourly breaks generally are appropriate, but consider providing more frequent breaks for highly repetitive or strenuous work.
* Schedule work so every worker has at least two consecutive rest days and at least one of these days is Saturday or Sunday.
* Avoid scheduling several days of work followed by four- to seven-day mini-vacations.
* Keep consecutive nights shifts to a minimum – four nights maximum in a row should be worked before a couple of days off and schedule no more than 48 hours of night shiftwork per worker per week.
* Educate workers on the importance of getting enough good sleep. Suggest they use black-out drapes, turn off phones and pagers and use a fan or white noise to mask daytime noises. Regular exercise, diet and relaxation techniques also are effective strategies for coping with night work.
* Consider alternatives to adopting permanent night shifts. Most workers never fully adapt to night shiftwork, since they go back to a daytime schedule during days off.
* Avoid quick shift changes and adjust shift length to the workload.
* Take into account all aspects of workers' job and home lives when changing work schedules.
* Provide a minimum of 11 hours off between shifts and a minimum of 24 to 48 hours when rotating workers off the night shift.
* Change from the night and morning shifts should happen between 7 a.m and 9 a.m., as starting the morning shift too early often cuts down on evening sleep time.
* Forward shift rotation – going from a day to afternoon or afternoon to night or night to day shift – is more compatible with normal sleep patterns than backward shift rotation.

Andy Brazier

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

Allocating blame for cable car crash

Article on BBC site 18 July 2006. Provides more information about the Nevis Range cable car crash that injured 5 people.

http://news.bbc.co.uk/1/hi/scotland/highlands_and_islands/5189324.stm

I am interested by the language used by Mr Hinteregger from the operating company. Couple of quotes:

"there must have been human error as the safety systems worked as intended"

"the company was not "in charge" of allocating blame, as that was up to the investigating authorities."

Red-face spellchecker

Article from Reuters 26 July 2006
here

TextTrust is a company that sells a service checking web sites for spelling errors. Unfortunately they issued a news release with multiple errors. "It said commonly misspelled words included independent, accommodation and definitely, which were spelled independant, accomodation and definately."

Oops

Pitfalls of nuclear power

Book titled 'Nuclear Power Is Not the Answer' by Dr Helen Caldicott is summarised at this web site

http://www.vheadline.com/readnews.asp?id=65443

Dr. Caldicott is President of the Nuclear Policy Research Institute. She has become "perhaps the world's leading advocate for the abolition of a technology too unsafe to be tolerated any longer."

Human error gets several mentions. See quotes below

"Many experts agree it's only a matter of when and where, not if, a devastating meltdown will occur in one or more of the 438 nuclear power plants located in 33 countries worldwide. It may result from human error, a plant owner's unwise or unsafe attempt to minimize operating costs, the Nuclear Regulatory Commission's (NRC) imprudent accession to industry pressure to allow 20 year operating extensions to plants designed to run only for 40 years, the effects of a tsunami or high enough magnitude earthquake in areas vulnerable to them or from a deliberate attack or internal sabotage."

And
"Every US power plant is moving into the old-age cycle" because no new ones have been built here since the TMI accident in Pennsylvania in 1979. As a result, the number of near-misses and near-meltdowns has increased mostly resulting from human error, aging equipment and inadequate maintenance and regulatory oversight. With the dangers so high and inevitable and the supposed benefits totally without merit, why would the leaders and residents of any community ever be willing to allow the construction or operation of a nuclear power plant near enough to them to destroy their lives should a catastrophic nuclear event happen as it surely will potentially at any of the world's nuclear plants.

Repetetive stress injuries (RSI)

Article "Exercise may be the rx for RSI" on LAtimes.com 7 August 2006. Suggests the cost of RSI to US industry may be as much as $100 billion annually if direct and indirect costs of lost productivity and absenteeism are included.

Response to RSI is often to invest in expensive ergonomic equipment. However, there have been very few studies to evaluate their effectiveness. This article suggests ergonomic equipment is good for prevention, but pain killers and exercise are likely to be more effective once someone has got RSI.

As well as being generally fit, it is important to take 3 to 5 minute breaks every 20 to 40 minutes, and frequent 10 to 15 second 'micro breaks.' "You must get out of your chair a couple of times an hour."

Article online at
http://www.latimes.com/features/health/la-he-ergonomics7aug07,0,7236861.story?coll=la-home-health

Similar article at
http://www.insurancejournal.com/news/international/2006/07/25/70711.htm

Thumb ache from texting

Article in Guardian online on 15 August 2006.

Warns that sending lots of text messages can cause pain and swelling of tendons at the base of the thumb and wrist. It seems mobile phones are not designed with the capabilities of the thumb in mind, which is "not a very dextrous digit."

However, a reader has added comment. "Please tell me this is a joke article. I really hope there hasn't actually been serious research done" on this topic.

http://blogs.guardian.co.uk/mortarboard/2006/08/thumbsoff_thursday.html

Blunders by NHS kill thousands of patients a year

Front page of Sunday Telegraph, 27 August 2006.

Quotes data from National Patient Safety Agency (NPSA) - "a total of 2,159 died after serious lapses in care by hospitals, family doctors' surgeries, ambulance trusts and in community and mental health care last year. A further 4,529 patients suffered severe harm because of avoidable mistakes." This is from a total of 500,000 reported patient safety incidents.

Apparently 165,135 people suffered harm while in NHS care. Of these
20,000 vulnerable patients managed to harm themselves whilst in care, with an unknown number committing suicide.
50,000 incidents involved patients being given the wrong medication
49,000 suffered errors during operations or other treatments
19,749 involved medical device failures
6,000 infection control incidents were reported.

We have to accept there will be a significant degree of under-reporting. The trouble is the NPSA do not seem to have any idea of what causes the errors, or make any evaluation of whether the risk is tolerable or not. It is a tragedy that people are harmed whilst in health care, but it will always happen. To evaluate the risk we need to at least have some understanding of what would happen if treatment had not been provided.

Meeting mixup

Had one of those heart stopping moments yesterday. It is the last week of the school holidays, and I had taken a day out from work to go out with the family. Mobile phone rings. It is one of my clients. He asks "are you nearly here?"

Now I have a meeting scheduled for the next day, which I point out. Reply is "no definitely today. The guy from the Netherlands has arrived to see you."

Anyway, turns out the email I received said the meeting was on Wednesday 31st. Should have said Wednesday 30th. What interests me is why I latched onto the date and the client latched on to the day, so that neither of us realised the error.

Being freelance, I don't tend to work a standard week. Work comes in small bursts, and I had recently been doing some work over the weekend. I don't have any particular reference points related to the day of the week, so probably consider the date more.

In contrast, when you have a 'proper job,' life is much more closely related to the Monday to Friday week. Hence, I can see that the day is of more interest.

Equally, when I got the phone message, I did wonder if I had made a mistake. I remember making a mental note that the meeting was on the last day of August, as a way of remembering. It would have been quite easy for me to have made this note for a meeting on the 30th, as I usually have to give some thought to which months have 30 and which have 31 days.

As it turned out we managed to cover everything important on the phone. I spent the day with the family and avoided a drive across country to go to the meeting.

Drowsy driving

According to this article
http://www.tnn.co.uk/UKNews/plonearticle.2006-08-21.2124105117

Loughborough university have tested how good sugar and caffeine are at keeping us awake. They conclude that a 'sugar rush' is not effective, and that to have "a drink that contains more useful amounts of caffeine and combine this with a short nap" is best. High sugar in caffeinated drinks seems to counteract the effect of the caffeine.

Egyptian train crash

Reported to have killed 'dozens' when one train went into the back of another. Human error is being cited as the cause, suggesting a driver passed a signal. Interesting to note that the head of the state railway authority was fired and his deputy suspended before the inquiry had reached any conclusions. It seems that the rail authority has been seen as being generally lenient regarding safety for some time, and there is motivation to maintain standard.

http://today.reuters.co.uk/news/articlenews.aspx?type=worldNews&storyID=2006-08-21T193532Z_01_L21330896_RTRUKOC_0_UK-EGYPT-TRAINS.xml&pageNumber=0&imageid=&cap=&sz=13&WTModLoc=NewsArt-C1-ArticlePage3

Risk management - new guidance from HSE

I noticed this on the HSE home page a few weeks ago. At first it looked good, examples of how to do risk assessments. However, my view is that a fundamental aspect of risk management is that opportunities to remove hazards, followed by reducing hazards are taken before controls are considered. This seems to be completely overlooked in the examples provided.

I have written to HSE about this and received a reply saying they have debated this point internally and concluded that what they provide is a 'good enough' solution. I don't agree, especially with the ever increasing requirements for risk assessment including fire, stress, ATEX.

The new guidance is at http://www.hse.gov.uk/risk/index.htm

Cable car accident

There has been an accident on the Nevis Range cable car system in Scotland. See article at http://news.bbc.co.uk/1/hi/scotland/highlands_and_islands/5178870.stm

We had a great day out on this last summer when we were touring the area. It was our younger son's birthday treat, before going to MacDonalds in Fort William for lunch (his idea, not ours).

It will be interesting to see what the cause comes out to be. More immediately, how to you balance risks with having a good time. Of course there must be risks from cable cars, but people seem to expect that everything can be made risk free. We have a cable car system in Llandudno, but it has not worked for several years (I don't know why). I doubt this accident will help its restart.

Radiation risks

There was a very interesting edition of Horizon on BBC2 last night. See write-up here http://news.bbc.co.uk/1/hi/sci/tech/5173310.stm

Looking at data from Chernobyl, the cases of cancer following the accident are far lower than expected. The suggested reason is that the predictions were based on data from the Hiroshima and Nagasaki nuclear bombs. Whilst these provided plenty of data for high doses of radiation, the effect of low doses was determined on a straight line graph, suggesting all levels of radiation have some risk. The basic premise of the Horizon program was that there is a minimum threshold, below which there is very little risk and in fact some data suggests it may be beneficial.

I had always naively assumed that when it was reported that 2,000 or 20,000 people had died prematurely as the result of Chernobyl, that this was based on medical data (i.e. the actual number of people that have died). It actually turns out that this was probably based on projected figures. A good example of where a projected figure is published, and over time it starts to be quoted as an actual result.

I have often wondered if we can get useful data from animals. They were not evacuated from region after the accident, and even today there are sheep in the UK that are considered too contaminated for human consumption. The program did follow this line of investigation, and claimed that there was no evidence that animalimal populations were suffering from the effects.

ossibly more harmful than the actual exposure.

Emails deleted from server

Apparently PlusNet have wiped a load of emails from their server during a system upgrade. It is estimated 700 GB of data was lost when a a senior engineer mistook the management interface of a live email server for that of a backup server, and erased all the data on the wrong one.

Company representative Ian Wild has assured disgruntled members: "It was a genuine mistake, an accident, and I'm afraid no measure of change control procedures or anything else would have completely prevented this. At the end of the day, all we can do is hold our hands up here and say that although an unfortunate set of events, this should never have happened… you can never remove the risk of a human error entirely."

Interesting how companies start to say human error cannot be totally eliminated when they think it might get them out of paying compensation. Conversely, they choose to blame individuals for making errors (i.e. suggesting errors are preventable) when they think that transfer the heat from the company. Or am I being cynical?

Article is at

http://news.zdnet.co.uk/communications/0,39020336,39278586,00.htm

Basic ergonomics

Although I am a registered member of the ergonomics society (virtually equivalent to being chartered - but the society does not yet have chartership available) I rarely get involved in what I call 'basic ergonomics.' To me this is the occupational health side, whereas I usually deal with major hazard risks and more interested in human error and system safety.

Found this useful summary of 'eight ergonomic essentials' at http://www.freelancenews.com/lifestyles/contentview.asp?c=189667&siteID=33

1. Move frequently - "the best position is the next position."
2. Rest frequently.
3. Use proper postures - maintain the spine's natural curve
4. Keep an eye on vision - make sure things are at or just below eye level and in front of you at a comfortable viewing distance
5. Organise things into your reach zone
6. Use the right tool for the task
7. Don't be afraid to ask for help
8. Listen to your sensible self - look at what you are doing and ask if things could be arranged better

Unable to use the emergency phone

Continuing my theme of problems caused by technology. Talking to some people recently. They have to communicate with an offshore platform. There was a problem with the 'land-line' phone system. Following previous problems, they had been provided with a satellite phone. Unfortunately they had never used it before, and were not sure how to use it. Also, they did not know what number to call to contact the platform.

People seem to assume new technology creates automatic improvement. This is clearly not the case.