How many times have you heard it? “We need industrial workers to stop making mistakes.” It’s a simple concept; get your plant workers to stop making the kind of bad choices that seem so obvious in hindsight. It’s usually easy to find that person too. They took the final action that initiated the event and probably still have their finger on the button with an “aww crap” look on their face… if they aren’t off getting medical attention. But as with most things, when it seems simple and easy we are probably missing the big picture.
First, a word of caution: In our previous blog we introduced the basic human error reduction concept of REMEDY; Reduce Errors, Manage, Error Defenses, and Yield. We usually all agree at the onset that we need to address all of the above; the industrial worker making mistakes (RE), the managers leading change (M), how the organization can defend against errors (ED), and how to anticipate and design outcomes (Y). Organizations often fail to transform their culture because they focus too much on RE and “If we could just get people to stop making mistakes…” To be clear, there are distinct actions, roles, and responsibilities to address active, worker errors (which will be the focus of this blog) but keep in mind that although this an important step it's not entire solution.
Per the Department of Energy, industrial workers are usually set up to make mistakes about 70% of the time. They quite often do a good job of avoiding errors, but periodically they will take an action that results in damaged equipment, lost time, injury, or a fatality. It’s going to happen. Even your very best will make mistakes. To err is human and we won’t completely eliminate human error. However, we can reduce the frequency and severity of errors. This is why NFPA 70E wants us to start addressing it. First, we need to identify the factors that make errors more likely. These are called human performance “traps”
· Time Pressure
· Vague Guidance
· Mental Stress/Fatigue
· Peer Pressure
· Physical Environment
For more information on each trap watch, the corresponding TOPI Trap training video.
We need to teach our workers to recognize when an error trap is present. It’s important to recognize that the goal is to eliminate the trap if possible, but as you can probably surmise, not all traps can be eliminated. In these cases, it’s important to mitigate the impact of the trap by utilizing a human performance “tool”.
· Self Check
· Questioning Attitude
· Effective Communication
· Peer Check
· Second Check
· Post Job Review
· Procedure Usage
· Critical Step Check
For more information and an example of each tool, watch the corresponding TOPI Tool training video.
If industrial workers can create the habit of taking the time to recognize traps and utilize tools, we will significantly reduce the frequency and severity of errors. The data is in and Human Performance methodologies work. However, this is just our workers acting as the last line of defense. We need to reduce the number of hazards we are asking our workers to mitigate through creating effective management (M) engagement and error defenses (ED); the subjects of our next two blogs. Stay tuned.