‘We are not learning from our investigations,’ ‘The same incidents keep happening,’ ‘We are not communicating with each other.’ ‘But we mostly have technical investigations.’
We hear these sort of statements over and over again as we speak to companies worldwide. At the same time, despite much anxiety over the topic, there is bewilderment and a flawed understanding about what actually causes incidents and about the interface between people and machines. Seeing the ‘big picture’ seems to be a struggle. Thinking around the human element of failure seems to pose difficulties. Why is this?
Well, for one thing, it is becoming apparent that, the kind of people who are selected – and apply to become – industrial managers, have the kind of minds which don’t work that way. There is a bias. They naturally seem to prefer certainty, measurable things, and clear categories. Understandably. And this is how human factors is approached. Very often, despite there being some excellent writing and information on the topic available, there is a need to ‘capitalise’ Human Factors and turn it into a technical term, to see it as something separate and tangible, territory with a kind of mystique, to be feared as almost impenetrable, less manageable than machines. So, ‘Human Factors’ have to be explained, at length, using complex language (jargon?), often by psychologists.
To see human interaction with tasks and machines as inevitable, inextricably linked in any work, or life situation, is too messy for many. But it is only by looking at ‘causes’ as being a multifactorial mix of people, machines and a given environment, can we begin to understand them as being unavoidably inter- linked, as all part of the mix. By identifying them all and understanding their interplay, we can, by careful and logical analysis, wend our way to a clear understanding of any given event. Only by good, all embracing investigation, followed by competent RCA, taking all factors, human and otherwise, in all their ‘messiness’, into account, can we uncover the information we want. This information is the basis of learning from incidents.
A major company recently told us that they use System A for technical investigation, System B for minor incidents, System C for looking at barriers and a fourth, System D for when they needed to identify human error. No one seemed to have an overview and their question was, ‘Why do we not learn from incidents?’ They don’t because they are still trying to separate out all the causes, especially Human Factors, which always seems to need capital letters!
There is no mystique. The two resources we recommend for ‘getting started’ in the fascinating territory of the human element in incidents are:
‘HUMAN FACTORS – How to take the first steps.’ www.stepchangeinsafety.net
www.humanfactors101.com – Personal website/blog of Martin Anderson.
Both resources are clear, straightforward, interesting and hugely helpful.