MANUAL HANDLING & ERGONOMICS
AVOIDING THE PITFALLS
The Health & Safety Executive here explore the prevalence and consequences of human failure.
Everyone can make errors no matter how well trained and motivated they are. However in the workplace, the consequences of such human failure can be severe. Analysis of accidents and incidents shows that human failure contributes to almost all accidents and exposures to substances hazardous to health. Many major accidents such as Texas City, Piper Alpha and Chernobyl, were initiated by human failure. In order to avoid accidents and ill-health, companies need to manage human failure as robustly as the technical and engineering measures they use for that purpose.
The challenge is to develop error tolerant systems and to prevent errors from initiating. To manage human error proactively it should be addressed as part of the risk assessment process, where:
• Significant potential human errors are identified.
• Those factors that make errors more 24
or less likely, known as Performance Influencing Factors (PIFs) are identified, including poor design, distraction, time pressure, workload, competence, morale, noise levels and communication systems.
• Control measures are devised and implemented, preferably by redesign of the task or equipment.
It is important to try and learn lessons following an incident or near miss. This involves identifying the human errors that led to the accident and those factors that made such errors more likely.
TYPES OF HUMAN FAILURE It is important to be aware that human failure is not random; understanding why errors occur and the different factors which make them worse will help employers develop more effective controls. There are two main types of human failure: errors and violations.
A human error is an action or decision which was not intended. A violation is
a deliberate deviation from a rule or procedure. HSG 48 provides a fuller description of types of error, but the following may be a helpful introduction.
Some errors are slips or lapses, often “actions that were not as planned” or unintended actions. They occur during a familiar task and include slips (e.g. pressing the wrong button or reading the wrong gauge) and lapses (e.g. forgetting to carry out a step in a procedure). These types of error occur commonly in highly trained procedures where the person carrying them out does not need to concentrate on what they are doing. These cannot be eliminated by training, but improved design can reduce their likelihood and provide a more error tolerant system.
Other errors are mistakes or errors of judgement or decision-making where the ‘intended actions are wrong’ for example where we do the wrong thing believing it to be right. These tend to occur in situations where the person does not know the correct way of carrying out a task either because it is
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