I've watched a few threads here regarding accidents at work with interest, accidents in the workplace, on company supplied transportation, on the ground and in the air. My daily work includes educating and informing employees about "Safety at Work". I'm an Incident Investigator and on the unfortunate occasions when an incident occurs, my area of involvement is to identify "Human Factors" rather than technical failures, and identify root causes. My question is, how many of you in other areas of maintenance work are involved in "Human Factors" research and what are your experiences. I'm not asking for materials or guidance (I have a whole raft of books by James Reason that I use as reference) rather I'm asking about other peoples experience of how human factors contributed to accidents and incidents at work.

Mal It's a good question, but I doubt I can provide as good an answer. In my own industry I have investigated many accidents, however historically the HFs (ergonomics) tend to be overlooked except for perhaps the more serious disasters. One of the reasons is that the investigator is acutely aware that they have no influence over the HFs. Hence there is not much point in dwelling on something which cannot be changed via the investigation. A recent example is troughing, usually heavy concrete boxes and lids for storing linseside cables. There are thousands of miles of troughing, which due to the heavy and unwieldy nature cause many injuries from manual handling to hand/finger/foot injuries. Designers and manufacturers need to be smarter and design robust equipment from lightweight materials. There are some products which can be used but still the concrete troughing is normally the preferred choice of clients. Ray

I'm puzzled by the idea that human factors can't be addressed. Human factors doesn't mean "it was just the individual's fault"! When I identify human error in an investigation I classify it following HSG48 and try to identify the organisational, job and individual factors and then see which ones can be addressed. That's the point of identifying human factors!

Thanks for your responses, as I said at the start, I,m not really looking for advice I,m comfortable with how things are dealt with here. I wanted to here about incidents to open up a general discussion

Not sure if this is what you wanted, but In my last position I tried to group accidents by type / cause etc and found they were all different, looked at all the usual things; time of day, holiday periods, accident categories etc, no common theme. I then looked back over the previous 4 years worth of accident data, still nothing. I then chose to look at the accidents not from category ie slip trip or fall from height etc, but their underlying issue. I found that nearly all accidents fell into one of two types of HF (management issues aside). They were failure to know their own limits and failure to be aware of their immediate surroundings. So accidents like over reaching into a van to pick something up and stepping off something in a position they should not as it is just a little too high, both are issues relating to their own ability. Its the grey area between ok and far to much ( weight or distance etc) that was where the issues came from. No one tries to pick up a tonne, but 50Kg may give it a go. We tell people that everyone can pick up different amounts and they should not pick up more than they can handle, but how do they know that until they have exceeded it at least once. Hope this helps with your discussion. Chris

Just in case my last post read like an advert - you asked for experiences, well here goes. Most of the businesses I deal with require me to sign non-disclosure agreements but I think it is fair to say one of the things I come across most often is peple either not reporting near misses or feeling awkward about getting involved in situations where they have seen something is wrong. Typical examples include people working against procedures and ending up getting electric shocks or exposed to toxic gases (both have happened at businesses I have been called in to) despite others seeing that there were problems and not intervening. To point others (I know you are not interested in advice per se) in the right direction for such instances I would suggest bystander intervention is a good place to start. Also, the way we view our actions could be refernced via Fiery Cushman's work.

For example, in 1954 a Comet Airliner being operated by BOAC (And yes I'm old enough to remember that flag waving banner) crashed into the sea off the coast of Italy after breaking up in mid air, all 35 on board were killed. The aircraft was built to the design standards of the day, but nobody at the time new of the effects of multiple cabin pressurisation cycles and how they would act on an area of structural weakness, (Technical Failure) In the 1990s a Hawk aircraft crashed because a technician disconnected a flying control system control rod during prep for an NDT Inspection but didn't record it and it was omitted from the subsequent handover (Human Error)