The Dirty Dozen of Human Factors: 12 Causes of Incidents
Understanding the root causes of incidents is crucial to understanding why a particular incident occurred and how to reduce the likelihood of it happening again. One generalised explanation often used as a cause of incidents is ‘human factors related’ or ‘human error’, but this is too generic. The Dirty Dozen refers to the 12 most common human factors that can usually be attributed to such incidents. These precursors, or preconditions, are responsible for a significant portion of workplace incidents and understanding them can help organisations take proactive steps to minimise them and reduce risk. It is not, however, a comprehensive list of incident causes.
What is the concept of ‘The Dirty Dozen’?
As mentioned above, the Dirty Dozen of human factors refers to the 12 elements that can influence people to make mistakes, therefore leading to workplace incidents. The concept was first created by Gordon Dupont in 1993 as part of his work in the aviation maintenance industry, but as they have become more widely known as the most common causes of incidents, the Dirty Dozen are recognised as being applicable across a variety of sectors and industries. The list does not present an order of importance or relevance as an individual or organisation can be subject to all 12 factors equally, sometimes without even realising it.
In this post we’ll describe the factors individually, how they contribute to incidents, and what can be done to counteract them.
Lack of Communication
Lack of communication refers to a miscommunication or a failure to transmit or receive important information between the organisation and individuals in the workplace. This factor can cause incidents as it can create misunderstandings leading to wrong choices. An example of this could be if a safety procedure or protocol isn’t communicated effectively, then employees cannot follow it correctly.
To counteract this, it is essential that detailed information is passed on before, during and after a task, and confirmed at each stage. Make sure that complex information is also written down as, with verbal communication, it is common that only 30% of a message is understood. Communicating verbally can be kept short with the most important information mentioned at both the start and the end, whilst also giving an opportunity for questions to confirm understanding.
Complacency
Complacency within the human factors Dirty Dozen refers to a feeling of uncritical satisfaction that is often accompanied by a lack of awareness. In the context of the workplace, it can apply to an individual whose role involves conducting routine activities. These activities can then become habitual resulting in overconfidence and a lack of awareness, which can lead to slip ups or missing important signals and risks.
It can be difficult to prevent a sense of complacency in the workplace, especially in situations where individuals have been working in the same role for many years. Regular training and added stimulus can be a prevention method such as inspections, or increased vigilance or variations. For example, swimming pool lifeguards move stations every 15 minutes. It is also important to avoid working from memory and to always cross-check work with another team member if possible.
Lack of Knowledge
Insufficient training or experience can lead to incidents by people in the organisation making mistakes because they simply don’t know the correct procedures to follow or are unaware of potential hazards.
It is essential in this case that all staff are continually undertaking professional development in order to identify any knowledge gaps. In the case of incident investigation training, we offer courses for the beginner and also refresher investigation training for those looking to keep their skills up to date.
Distraction
Distractions can divert attention from the task at hand, leading to mistakes or omissions and therefore causing incidents. In the workplace, some distractions are unavoidable such as loud noises and requests from team members. However, others can be avoided or delayed until a more appropriate time such as non-urgent messages from home and conversations regarding non-immediate work matters. Additionally, distractions can result in forgetting things or where we are in a task. Keeping checklists can remind employees of all the necessary steps in a procedure and can help prevent getting lost, but the best way to prevent distraction is to complete the task at hand before responding.Lack of Teamwork
In aviation and many other sectors, tasks and operations are about a team effort and no single individual can be responsible for the safe completion of every task. Workers rely constantly on the support of each other and when someone is not contributing to the team effort, it can lead to operations not running smoothly and, therefore, incidents. It is so important to ensure that every member of a team knows their individual responsibilities and is also committed to working together towards a common aim.Fatigue
Fatigue can be defined as a feeling of constant exhaustion, burnout or a lack of energy. It can affect individuals physically, mentally or a combination of both. Often it is a reaction to prolonged physical work or mental stress for example, following long periods of work. Fatigue can be one of the causes of incidents as it can impair a person’s cognitive function and decision-making, increasing the likelihood of mistakes. Being aware of the signs and symptoms of fatigue in both yourself and others is crucial in making sure that you are not underestimating your level of fatigue.Lack of Resources
A lack of resources can signify simply a lack of equipment needed to complete a given task but it also refers to an inadequate level of personnel, time or support. It can force team members to take shortcuts or work under unsafe conditions and this is how it causes incidents. Tasks are completed more thoroughly and correctly when the appropriate resources are available, so forward planning is important to ensure that this Dirty Dozen human factor isn’t the cause of an unwanted incident.Pressure
Working in a pressurised environment can often be expected when working in such high-risk situations where incidents are likely to occur. However, the problem comes when the pressure to meet a deadline interferes with being able to safely complete work. Rushing to meet a deadline can be considered an incident because people forgo safety procedures or standards of work in order to meet said deadline. In order to counteract pressure, individuals can learn assertiveness skills allowing them to say ‘no’ and communicate concerns about deadlines or situations of pressure with others in the organisation. Management and those setting tasks may need to be more realistic on time scales based on similar tasks that have been completed previously.Lack of Assertiveness
Following on from this, lack of assertiveness can lead to incidents when those who are unable to express concerns fail to speak up if they notice a potential danger. This can lead to unaddressed safety issues and, consequently, a potential incident. Learning to communicate directly and openly and practising assertiveness techniques can help reach a productive conclusion to criticisms raised in the workplace and establish actions that need to be taken to prevent an incident. It helps to have an open culture of learning that facilitates this too.Stress
Similar to fatigue, stress is a physical and emotional state that can damage the body. It can seriously affect a person’s concentration, decision-making and overall performance, making errors more likely and increasing the risk of incidents. Read more about stress in the workplace, how it causes incidents and methods for prevention in our dedicated blog post.
Lack of Awareness
A lack of awareness can come from working in isolation or having tunnel vision for your own responsibilities. We can therefore have a lack of awareness of how our actions can affect other individuals or processes in an organisation. Additionally, it can also refer to an ignorance of potential hazards in the surrounding environment. Understanding the roles and responsibilities of the people around you is essential in developing the foresight to pre-empt the way our actions can have an effect on others. Vigilance is also a key skill in monitoring the environment and people around us. General awareness of safety and the impact of human factors on incident causation is important too.Norms
Norms in human factors refers to the practices that become commonplace as a workplace and its culture develops over time. These practices or ‘norms’ aren’t necessarily always unsafe but they can follow unwritten rules or deviate from the standard procedures that need to be followed. Norms are therefore not designed to meet all circumstances or threats in an organisation and so can be the cause of incidents. Ensuring that the proper rules and safety procedures are taught, enforced and followed is a way to mitigate the negative consequences of norms, as well as addressing any instances where employees are deviating from them.Reducing the Influence of the Dirty Dozen with Incident Investigation Training
Understanding the Dirty Dozen of human factors and how they contribute to incident causation is just the first step in learning how to prevent them from causing incidents in the future.
Implementing consistent and effective investigation training can be another piece in the puzzle to reduce the influence of these factors in your workplace. Incident investigation training can help with:
- the identification of Root Causes and the underlying human factors contributing to incidents;
- promoting and cultivating a culture of safety where everyone in the organisation is more aware of these factors, their implications and how to mitigate them;
- continuous learning and improvement of processes, reducing the likelihood of repeat incidents and enhancing overall operational performance;
- empowering employees to recognise and address human factors in their day-to-day work, leading to safer, more effective operations.
The Dirty Dozen of human factors are significant but not all-encompassing contributors to workplace incidents. However, as people and organisational factors are at the root of most incidents, with the right training and awareness, their impact can be greatly reduced. By investing in incident investigation training such as the Kelvin TOP-SET methodology, which enables employees to develop skills and recognise these factors in their own workplace, your organisation can not only prevent future incidents but also foster a culture of continuous improvement and operational excellence.
