Reducing error and influencing behaviour

Executive Health and Safety Executive ‘Reducing Error And Influencing Behaviour’ examines human factors and how they Reducing error and can affect workplace health and safety.

Reducing error and influencing behaviour influencing behaviour aviour This study looks at: actors and how

d by these ■■ The general impact of human error and behaviour; How workers’ physical and mental health can be affected by these s arising from

proached

als and ■■ and other factors; ■■ Practical ideas on how to identify, assess and control risks arising from such issues; and ISBN 978-0-7176-2452-2 ■■ Case studies detailing how various organisations have approached 9 780717 624522 these challenges. HSG48

https://books.hse.gov.uk/

02/08/2018 09:49 Especially suitable for managers, health and safety professionals and HSG48 (Second edition) employee representatives. Published 1999

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© Crown copyright 1999

First published 1989 Second edition 1999

ISBN 978 0 7176 2452 2

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This guidance is issued by the Health and Safety Executive. Following the guidance is not compulsory, unless specifically stated, and you are free to take other action. But if you do follow the guidance you will normally be doing enough to comply with the law. Health and safety inspectors seek to secure compliance with the law and may refer to this guidance.

Contents Introduction 4

Chapter 1 What are ‘human factors’? 5

Why should I be interested in human factors issues at work? 6 How do I know if these problems exist in my organisation? 6 Isn’t it just about people ‘taking more care’? 7 This seems to be a very broad topic area, where should I start? 7 Isn’t this going to be costly? 7 Should I seek the views of the workforce and their representatives? 8 What kind of control measures are possible? 8

Chapter 2 Understanding human failure 9

Human failure and accidents 9 The human contribution to accidents 11 Causes of human failure 12 Breaking the rules 16

Chapter 3 Designing for people 19

Ergonomic design 19 Designing jobs for mental well-being 21 Writing procedures 24 Designing warnings for maximum effect 27 Human Reliability Assessment 28

Chapter 4 Managing the influences on human performance 31

Fatigue and shift work 31 Effective shift communication 33 Focusing on behaviour 34 Health and safety culture 39

Chapter 5 Getting started 42

Where do I start? 42 Human factors in risk assessments 42 Human factors when analysing incidents, accidents and near misses 44 Human factors in design and procurement 44 Human factors in other aspects of health and safety management 45 How can I do all of this? 45 Checklist for human factors in the workplace 46

Chapter 6 Case studies: Solutions to human factors problems 47

Acknowledgements 69

Glossary 69

References 70

Further information 73

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Reducing error and influencing behaviour Reducing error influencing behaviour

Introduction This guidance is aimed at managers with health and safety responsibilities, health and safety professionals and employee safety representatives.

The message is that proper consideration of ‘human factors’ is a key ingredient of effective health and safety management. Human factors is a broad field and organisations may have viewed it in the past as being too complex or difficult to do anything about. This guidance aims to overcome such fears by providing practical help on how to tackle some of the important issues.

The guidance:

n explains how human error and behaviour can impact on health and safety; n shows how human behaviour and other factors in the workplace can affect the physical and mental health of workers; n provides practical ideas on what you can do to identify, assess and control risks arising from the human factor; and n includes illustrative case studies to show how other organisations have tackled different human problems at work.

The format of the publication is as follows:

Chapter 1 provides an introduction to human factors. Chapter 2 looks at types of human failures, their causes and ways of reducing them. Chapter 3 considers how to improve health and safety at work through better design of tasks, equipment, procedures and warnings. Chapter 4 looks at some key operational issues: shiftwork and fatigue, shift communication, risk perception and behaviour, and health and safety culture. Chapter 5 provides some hints on how to get started. Chapter 6 presents a series of case studies which illustrate practical cost-effective solutions to real human factors problems. Tables enable you to read only those cases which are most relevant to your organisation and problem area. Some of the approaches shown in this guidance represent ‘good practice’ rather than what is strictly required by legislation.

The guidance cannot cover every aspect of human factors. It introduces some key influences on peoples’ behaviour and work performance which need to be included in a health and safety management system. References are given including references to general books on human factors. A list of relevant professional societies and a glossary of terms is also provided.

This publication is a revision of guidance originally published in 1989 Human factors in industrial safety. This major revision reflects improvements in our understanding of human error and human behaviour at work and the need to carry out risk assessments which take account of these issues.

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Chapter 1 What are ‘human factors’? The HSE definition is: ‘Human factors refer to environmental, organisational and job factors, and human and individual characteristics which influence behaviour at work in a way which can affect health and safety’. A simple way to view human factors is to think about three aspects: the job, the individual and the organisation and how they impact on people’s health and safety-related behaviour.

Figure 1 Human factors The job - Tasks should be designed in accordance with ergonomic principles to in occupational health and take into account limitations and strengths in human performance. Matching the job safety to the person will ensure that they are not overloaded and that the most effective contribution to the business results. Physical match includes the design of the whole workplace and working environment. Mental match involves the individual’s information and decision-making requirements, as well as their perception of the tasks and risks. Mismatches between job requirements and people’s capabilities provide the potential for human error.

The individual - People bring to their job personal attitudes, skills, habits and personalities which can be strengths or weaknesses depending on the task demands. Individual characteristics influence behaviour in complex and significant ways. Their effects on task performance may be negative and may not always be mitigated by job design. Some characteristics such as personality are fixed and cannot be changed. Others, such as skills and attitudes, may be changed or enhanced.

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The organisation - Organisational factors have the greatest influence on individual and group behaviour, yet they are often overlooked during the design of work and during investigation of accidents and incidents. Organisations need to establish their own positive health and safety culture. The culture needs to promote employee involvement and commitment at all levels, emphasising that deviation from established health and safety standards is not acceptable.

Figure 1 lists some of the key issues for each area. By thinking about these aspects you are asking questions about:

■ What are people being asked to do and where (the task and its characteristics)? ■ Who is doing it (the individual and their competence)? ■ Where are they working (the organisation and its attributes)?

Why should I be interested in human factors issues at work?

Careful consideration of human factors at work can reduce the number of accidents and cases of occupational ill-health. It can also pay dividends in terms of a more efficient and effective workforce.

Accidents can occur through people’s involvement with their work. As technical systems have become more reliable, the focus has turned to human causes of accidents. It is estimated that up to 80% of accidents may be attributed, at least in part, to the actions or omissions of people. This is not surprising since people are involved throughout the life cycle of an organisation, from design through to operation, maintenance, management and demolition. Many accidents are blamed on the actions or omissions of an individual who was directly involved in operational or maintenance work. This typical but short-sighted response ignores the fundamental failures which led to the accident. These are usually rooted deeper in the organisation’s design, management and decision-making functions.

Work has an impact on people’s health as well as on their safety. A positive work experience leads to job satisfaction and contributes to physical and mental well- being. Well-designed tasks and working environments that suit people’s individual skills and capabilities can help here. Physical health problems can result from lost- time injuries such as slips and falls, and from manual handling problems. Mental well-being can be affected if someone witnesses a traumatic event, suffers bullying or violence at work, or experiences stress at work.

How do I know if these problems exist in my organisation?

You will know you need to think about human factors issues at work by looking out for some relevant indicators like those given in Box A.

Accidents involving staff, contractors or visitors where ‘human error’ is given as a cause Occupational health reports of mental or physical ill-health High absenteeism or sickness rates High staff turnover levels Low level of, or changes in, compliance with health and safety rules Behaviour or performance issues identified in risk assessments Complaints from staff about working conditions or job design

Box A Some indicators of human factors problems

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Isn’t it just about people ‘taking more care’?

No. It is quite wrong to believe that telling people to take more care is the answer to these problems. While it is reasonable to expect people to pay attention and take care at work, relying on this is not enough to control risks. Box B shows what can happen if complacency about risks is combined with a belief that ‘taking care’ is a suitable control measure.

A farm worker was crushed under the wheel of a manure spreader which was being reversed between a building and a retaining wall for a distance of about ten metres.

The driver was asked by the farm worker to move the tractor and spreader to allow access for cattle into a yard. He agreed to move it and intended to reverse it into another yard. When he got into the tractor, the farm worker was standing by the nearside of the tractor. He started the engine and looked over his right shoulder and reversed. After four or five metres he heard a scream and found the worker lying under the nearside of the spreader in front of the wheel. A witness had apparently seen the farm worker fall under the wheel.

The ground was very muddy and the soles of the farm worker’s boots had become smooth. The tractor was large and not fitted with rear view mirrors as it was not used on the highway.

Everyone (farm managers and employees) were complacent about the risks in reversing equipment and believed that if everyone ‘took care’ no accidents would happen. In this case there were a number of steps which could have been taken to reduce the risks, such as the provision of mirrors on the tractor, and checking and replacing of boots. However, these steps would not be implemented unless farm managers and employees took a more positive attitude to risk reduction.

Box B Employee crushed by reversing manure spreader

This seems a very broad topic area, where should I start?

Don’t be discouraged by the breadth of issues that are covered by human factors. This guidance will provide you with practical information to help you start to manage human factors in your organisation. In particular it should help you to make progress in addressing human factors in four main areas:

■ during risk assessments; ■ when analysing incidents, accidents and near misses; ■ in design and procurement; and ■ in certain aspects of day-to-day health and safety management.

It is a continual challenge to manage the risks to and from people at work so that they remain safe and healthy. Improving health and safety cannot rely just on improvements in technical and system factors. You need to tackle some of the important ‘people’ issues too.

Isn’t this going to be costly?

Many improvements will be at minimal cost and the ideas may already exist in your organisation. The set of case studies in Chapter 6 show you how straightforward many human factors changes can be. Even relatively small changes to tasks and the working environment can improve health and safety as well as productivity and quality.

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Should I seek the views of the workforce and their representatives?

Yes, this is vital. Both safety representatives and other staff know about their job and working conditions. They will have insights into how this impacts on their health and safety. They will be able to help you to identify key issues and may already have suggestions for improvements. You will need to prioritise these issues and allocate appropriate resources to carry through the actions. Proper planning before implementing changes includes consulting the workforce and their representatives. This will usually lead to any changes being introduced more easily and accepted more readily. Afterwards you will also need to check and review that the changes have been effective.

What kind of control measures are possible?

A range of control measures are available including: workplace precautions, risk control systems, and management arrangements.

Adequate workplace precautions have to be provided and maintained to prevent harm to the people at risk. These precautions include: procedures and warnings, safe systems of work, controls on equipment, alarms, safety instructions, communications arrangements, and machine guards. All of these need to be designed with the human in mind to make sure that they are used correctly and reliably. Ergonomic changes to the task and the working environment also help to reduce risks and can improve the physical and mental well-being of the workforce.

Risk control systems are the basis for ensuring that adequate workplace precautions are provided and maintained. Most of the activities where risk control systems are needed will involve people, eg maintenance, routine and non-routine operations, recruitment and selection, demolition, dealing with emergencies. Looking at ways of improving the human factors aspects of these activities, eg through training, selection, and job design, will enhance risk control.

A set of management processes is necessary to organise, plan, control and monitor the design and implementation of the risk control systems. HSE’s publication Successful health and safety management1 provides advice in this area.

KEY MESSAGES

Consideration of ‘human factors’ is a key ingredient of effective health and safety management. It involves:

■ thinking about relevant job, individual and organisational aspects;

■ addressing human factors in risk assessment, during accident investigation, in design and procurement and in day-to-day operations;

■ involving the workforce and their representatives; and

■ selecting from a range of effective control measures.

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Chapter 2 Understanding human failure Human failure and accidents

Over the last 20 years we have learnt much more about the origins of human failure. We can now challenge the commonly held belief that incidents and accidents are the result of a ‘human error’ by a worker in the ‘front line’. Attributing incidents to ‘human error’ has often been seen as a sufficient explanation in itself and something which is beyond the control of managers. This view is no longer acceptable to society as a whole. Organisations must recognise that they need to Table 1 Some illustrative consider human factors as a distinct element which must be recognised, assessed major accidents and managed effectively in order to control risks.

Accident, industry and Consequences Human contribution and other causes date

Three Mile Island Serious damage Operators failed to diagnose a stuck open valve due to Nuclear industry to core of nuclear poor design of control panel, distraction of 100 alarms 1979 reactor. activating, inadequate operator training. Maintenance failures had occurred before but no steps had been taken to prevent them recurring.

King’s Cross Fire A fire at this A discarded cigarette probably set fire to grease Transport sector underground station and rubbish underneath one of the escalators. 1987 in London killed 31 Organisational changes had resulted in poor escalator people. cleaning. The fire took hold because of the wooden escalator, the failure of water fog equipment and inadequate fire and emergency training of staff. There was a culture which viewed fires as inevitable.

Clapham Junction 35 people died and Immediate cause was a signal failure caused by Transport sector 500 were injured in a a technician