Ultimately almost everything comes down to behaviour.
When I studied for my Psychology degree many years ago, I reached the conclusion that pretty much everything ultimately came down to behaviour. If you have an earthquake and a building collapses, you could blame the earthquake. But in reality, a human designed a building that couldn’t withstand that earthquake. This can be traced to some behaviour or other that led to the design decision. The earthquake was natural and inevitable, the building design was discretionary. This may sound a little fanciful or extreme, but I promise you it isn’t. By studying and analysing human behaviour we can reduce and ultimately eliminate accidents in the workplace.
That there was a bold statement. It was a statement that addresses a classic interview question for HSE roles. “Is an accident rate of zero a realistic objective?”. In an academic sense, the answer is yes, of course. Every accident has a root cause, we mitigate the root cause and it can’t happen again. Eventually we can address all causes so there will be no more accidents.
If you are thinking that is ridiculous, then you are hitting on the problem. As soon as we think accidents are inevitable we are allowing them to happen. If your team have ever performed an investigation and concluded that it was an unavoidable event, then it would pay to ask again.
When equipment fails it has often not been maintained correctly. If it has been maintained correctly then it perhaps had a quality issue from manufacturing. If the build was fine then maybe there was a latent defect in the material, if everything else was fine, maybe the design was wrong. Ultimately, the equipment is man-made, therefore a failure is a human factor. If we do not recognise this, then we are introducing risk into our business.
This does not mean that every accident or near-miss investigation should result in blame of an individual. To settle on a result such as ‘it was her fault’ is not a root cause. We need to dig deeper into the reason why he or she made the mistake or performed the deliberate violation.
By using consequence analysis or applied behavioural analysis we can drill down deeper than the person and pin point the behaviour and behavioural cause that led to an incident. This means we can realistically prevent it from happening again.
So many companies stop their investigation when they identify a person. They then move on to disciplinary procedures or dismissal. All this ensures is that that person will not make that mistake again. It does not prevent it from happening in the future. If you identify the true root cause and find out why that person did what they did, you can remove the possibility of that event happening again.
This being said, we must ensure that we hold people accountable. Ensuring that the people responsible for an incident are involved in the mitigations is essential. Also, appropriate action provides a negative consequence to influence future behaviour. However, don’t be too swift to jump to a disciplinary process, it can be damaging to the safety culture in your business. Sometimes it is the right thing to do, but it should never be the default.
To err is human. This is a common statement, but it is not a defence. Yes, humans make mistakes. If those mistakes can result in a loss of life or an injury it is our duty to eliminate them.
If your incident investigation tool or procedure stops at human factor or error or violation then please consider updating it. If you do not truly understand the human cause you will not prevent the incident happening again.
If you can investigate a near miss or unsafe action and identify the cause of a routine violation or error you may well save someone’s life.