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prads  
#1 Posted : 19 March 2020 08:47:25(UTC)
Rank: Forum user
prads

Dear All,

Writing this due to some ongoing discussion with my team who is overtly focussing on human behaviors as root causes of accidents, and want to undermine the significance of the technical and procedures factors contributing to it.

To a great extent, I understand and accept that there is an human element involved in all the facilures, be it technical or procedural. But, while dissecting an accident should we ignore the weakness in engineering and procedural issues and focus more on 'why' the individual failed to pick up those weakness and modify his behavior.

I would like to hear more from experts here as to why it wouldnt be appropriate to attribute root causes of accidents to human behaviors? And to focus on engagement of people alone can fix the larger technical and system issues? How reliable is this approach, while I completely agree that engagement and focussing on human behavior is a very critical aspect to build an overall culture. But, does engagement alone solve the problem?

Looking forward to hear more on this.

Regards.

P

fairlieg  
#2 Posted : 19 March 2020 09:05:19(UTC)
Rank: Forum user
fairlieg

Huge subject!!!!

The main thing to be understood if the context that drives the behaviour.  You are quite right, the human behaviour is only the starting point un understand the context and root causes of the accident.

Local Rationality, why did it make sense to that person give the context and tier understanding of the situation.  If it makes sense to them it will make sense to someone else if they are put in a similar situation.  Aviation investigators do this all the time using flight simulators etc

Fundamental Attribution error, focuses on the personal traits of the person rather than the context there are some great examples of that https://www.youtube.com/watch?v=KftOL3BMqB4, https://www.youtube.com/watch?v=58Na0-C1e2U.

Take a look at the 5 principals of human performance, https://www.amazon.co.uk/Principles-Human-Performance-contemporary-updateof-ebook/dp/B07N1CB1KN

People will make mistakes

Blame fixes nothing

Context Drives Behavior

Learning is Vital

How we react to failure will affect how much we can learn

 

There are lots of resources

https://www.hophub.org/

http://preaccidentpodcast.podbean.com/

https://safetydifferently.com/

https://www.amazon.co.uk/Behind-Human-Error-David-Woods/dp/0754678342

https://www.safetysynthesis.com/wrkshp_2020/index.html

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CptBeaky on 19/03/2020(UTC)
RayRapp  
#3 Posted : 19 March 2020 10:04:29(UTC)
Rank: Super forum user
RayRapp

I agree with above post, a big subject.

Historically human error was blamed on the majority of accidents. Management was content to allow the operator to take the blame. However, we now have a better understanding of human factors and human behaviour. So whilst the majority of accidents are still caused by human error the more serious incidents normally involve a combination of causal factors i.e. planning, supervision, training, equipment, etc.

Taking an example of railways accidents, drivers passing a signal at danger (SPAD) the driver was blamed and often prosecuted following a fatal accident (assuming the driver survived). The Cullen enquiry in 2000 into the Ladbroke Grove and Southall train disaster completly blew the lid off the notion that train drivers were the main cause of train crashes. Since the enquiry, rail infrastructure has been fitted with TPWS, which prevents trains from passing a red signal at a junction. Hence train disasters have been consigned to history.   

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A Kurdziel on 19/03/2020(UTC)
A Kurdziel  
#4 Posted : 19 March 2020 10:25:20(UTC)
Rank: Super forum user
A Kurdziel

Of Human Behaviour can be assumed to be the Root Cause of most accidents. Basically people don’t behove like you would expect them to behaviour, or hope they would behave or assume that they would behave. But that is not really the Root Cause. The ultimate Root Cause is why people don’t behave like you would expect them to, the essential question is, why we are jot truly rational beings. In the past human behaviour was often used by organisations to blame individuals: essentially they argued that they have created perfect rational systems for managing Health and Safety only for those pesky employees to not use if properly, over and over again. Organisations rarely asked the question: why people did not do the rational thing, and keep making the same errors of judgement, over and over again?

The problem is that there are lots of possible answers, which touch on things like:  we have developed form a bunch of hairy apes that lived on the African Savanah 3 million years ago and our reasoning skills are still being compromised by instincts left over from those days.

There are social reasons, essentially we like to follow the herd and do what others do even if it is stupid (like panic buying bread and milk!); it could be genetic or down to the way are brains are wired.

Which of these answers is right is something that will keep people busy for many years (if we don’t all die out in the next 6 months due to a lack if sanitiser!)  

Edited by user 19 March 2020 10:25:52(UTC)  | Reason: spelings

andybz  
#5 Posted : 19 March 2020 10:46:33(UTC)
Rank: Forum user
andybz

We shouldn't shy away from identifying human error as a direct cause of
accidents but it is never a root cause.

For a simple resource to encourage understanding of why human errors occur
this prompt list from HSE of Performance Influencing Factors is useful
https://www.hse.gov.uk/h...nfactors/topics/pifs.pdf

Violations are another issue, where people break rules. But, in the vast
majority of cases people violate for very good reasons, usually to get the job
done because they get no person benefit. People can be squeamish about
identifying violations because they can lead to blame, but I would prefer to
know about them provided people act like grown-ups when considering why they
happen.



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A Kurdziel on 20/03/2020(UTC)
Roundtuit  
#6 Posted : 19 March 2020 10:58:46(UTC)
Rank: Super forum user
Roundtuit

Originally Posted by: andybz Go to Quoted Post
... in the vast majority of cases people violate for very good reasons, usually to get the job done...

Not sure I concur that to get the job done is a very good reason to violate albeit the excuse most often proferred

To me a very good reason to violate is when following the rules, training and procedures would directly result in death or major injury and by violation you prevent the outcome.

Normally such circumstances prove that the rules, training and procedures were wanting.

Roundtuit  
#7 Posted : 19 March 2020 10:58:46(UTC)
Rank: Super forum user
Roundtuit

Originally Posted by: andybz Go to Quoted Post
... in the vast majority of cases people violate for very good reasons, usually to get the job done...

Not sure I concur that to get the job done is a very good reason to violate albeit the excuse most often proferred

To me a very good reason to violate is when following the rules, training and procedures would directly result in death or major injury and by violation you prevent the outcome.

Normally such circumstances prove that the rules, training and procedures were wanting.

CptBeaky  
#8 Posted : 19 March 2020 11:35:35(UTC)
Rank: Super forum user
CptBeaky

Very simply, I don't blame human behaviour because I wouldn't know how to control that. Instead I look at the results of human behaviour and try to control those.

For example if I know that human behaviour will make a person take a shortcut, I will look at removing the shortcut or making the shortcut safe. If the person still takes the shortcut and gets hurt, I wouldn't blame the person I would blame the controls.

HSE Chris Wright  
#9 Posted : 20 March 2020 08:19:34(UTC)
Rank: Forum user
HSE Chris Wright

Human error/behaviour can be seen in cases as the immediate cause but certainly not the Root Cause. the only real time that human behaviour could be a root cause is in a violation scenario which is extremely rare cases. there are complex antecedents as to why a person chose to act in a certain way that led to the incident. it is only through investigating those antecedents shall you find the Root Cause. look at the work completed by Rasmussen for a more in-depth idea.

Brian Hagyard  
#10 Posted : 20 March 2020 08:33:55(UTC)
Rank: Super forum user
Brian Hagyard

Im with Chris on this one - the rout cause would be failure to have anticipated the human behaviour with lots of stages between the two.

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A Kurdziel on 20/03/2020(UTC)
RayRapp  
#11 Posted : 20 March 2020 09:26:09(UTC)
Rank: Super forum user
RayRapp

Some years back I completed an Accident/Loss Investigation and Evidence Gathering course sanctioned by IOSH, the trainer stated that the term 'Root Cause' was no longer appropriate. Accidents and incidents have multiple causes. Okay, you could argue some causal factors have more gravitas than others.

Since completing the course I have never used the term root cause. Unfortunately some accident/incident forms still use the term, which should be banished for good as far as I'm concerned. 

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aud on 21/03/2020(UTC)
Holliday42333  
#12 Posted : 20 March 2020 11:59:30(UTC)
Rank: Forum user
Holliday42333

See https://www.hse.gov.uk/humanfactors/topics/types.pdf

peter gotch  
#13 Posted : 21 March 2020 18:10:46(UTC)
Rank: Super forum user
peter gotch

Whilst sympathising with Ray's view that perhaps we shouldn't use the term "root cause", I think that human failure could be such a cause - in the scenario where senior executives have deliberately chosen not to the right thing.

Plenty of examples of this happening!

Most of the recorded ones involve large corporations, but there was also the owner of the car wash prosecuted for manslaughter after a victim of modern slavery was electrocuted.

But in such a case, nobody wastes time on a formalised root cause analysis.

AdamSykes  
#14 Posted : 22 March 2020 22:22:54(UTC)
Rank: New forum user
AdamSykes

Originally Posted by: Roundtuit Go to Quoted Post

Originally Posted by: andybz Go to Quoted Post
... in the vast majority of cases people violate for very good reasons, usually to get the job done...

Not sure I concur that to get the job done is a very good reason to violate albeit the excuse most often proferred

To me a very good reason to violate is when following the rules, training and procedures would directly result in death or major injury and by violation you prevent the outcome.

Normally such circumstances prove that the rules, training and procedures were wanting.

Indeed, in my experience the vast majority of accidents have been either someone just not thinking or violating procedures and rules to "get the job done" which I would never ever class that as a good reason.

By all means, if an employee thought a procedure was hindering a task then by all means raise the query with a supervisor who can look at the procedure but never ever just ignore rules and procedures and do what they hell you want just to get the job done. That's how people die unfortunately.

A Kurdziel  
#15 Posted : 23 March 2020 08:59:41(UTC)
Rank: Super forum user
A Kurdziel

“Indeed, in my experience the vast majority of accidents have been either someone just not thinking or violating procedures and rules to "get the job done" which I would never ever class that as a good reason.”

The question is why people not are thinking or violating rules.

If as suggested you look at HSG 48- “Reducing error and influencing behaviour” This explains why people   do these things and what we can do to either stop them doing this or mitigate them ie prevent them doing something stupid even if they want  to.

That is down to management, which as someone said is something we can deal us with. Simply putting it down to human error is fairly pointless since we cannot reprogramme people to think or follow rules. The only way to eliminate the human factor is to totally automate the process.

 

RayRapp  
#16 Posted : 23 March 2020 09:17:41(UTC)
Rank: Super forum user
RayRapp

Rule violations are not uncommon in accidents/incidents. The question is are those rules fit for purpose?

When I was a TU h&s rep I constantly reminded management that train drivers were violating rules, very often with the knowledge of managers, because the rules were either unweildy or not practical to implement.

Management were happy to turn a blind-eye, provided the trains kept running...that was always the bottom line.  

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A Kurdziel on 23/03/2020(UTC)
fairlieg  
#17 Posted : 23 March 2020 10:58:55(UTC)
Rank: Forum user
fairlieg

Agree with the above two posts

Workers violate rules and take short cut all the time, it’s normal behaviour. Maybe not desirable but normal, as such there are more questions to ask when we find violations rather that pointing at them as a cause.  What was the cause of the violation and more to the point why did they not get away with it this time. (ref Challenger Disaster, Normalisation of Deviation)

I think it was the late Jens Rasmussen that said workers experiment all the time.  Sometimes the experiment goes well and sometimes it doesn’t

Most of time things go well for the worker regardless of if they are following the rules (most of the time they don’t).  There is a tendency to tie the violation to the incident in isolation but we only find out about violations when things go wrong.

I said before what’s happening when nothing bad is happening?

Also we cant push blame up the hierarchy either don’t investigate functions in silos understand how they interact as this can cause leaders to behave in a way that can influence the context the worker operates in (organisations culture & psychology)

If you’re getting to the point where you think the worker is just an idiot you have to ask what’s wrong with the recruitment process and supervision that allows the “idiot” to get there in the first place….

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A Kurdziel on 23/03/2020(UTC), CptBeaky on 23/03/2020(UTC)
achrn  
#18 Posted : 23 March 2020 13:59:41(UTC)
Rank: Super forum user
achrn

While I agree that in most cases there is a reason why the 'human error' occurred, or why it was not corrected, or why it had such a signifcant impact, I think it is false to say the cause of an accident is never human error.  Sometimes people make mistakes.  'Human error' is a real thing, and sometimes it occurs even when someone was not taking shortcuts or violating rules, they just made a mistake.

Some errors are not the result of a choice to err. In the case of an accident that arises because a worker made a genuine mistake, and the systems were not robust enough to accomodate, trap or correct that mistake, I would have some difficulty saying that the root cause was the sytems not correcting the mistake - the origin of the  accident would be the mistake, not the failure to correct it. If that's teh origin, would that not be the root cause?

Brian Hagyard  
#19 Posted : 24 March 2020 08:17:48(UTC)
Rank: Super forum user
Brian Hagyard

and the systems were not robust enough to accomodate, trap or correct that mistake

There is your underlying/root cause - the human error is the immediate cause. For me the question nowwould be is it reasonably practicable to correect that root cause - and sometimes the answer will be no. Yes we all make mistakes, the predictable ones we should try to control, the unpradictable ones we have no chance with.

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A Kurdziel on 24/03/2020(UTC)
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