Does human error cause accidents?

By Gary Rowe*
Thursday, 03 June, 2010

The term ‘human error’ has been part of the daily language for a long time. It may appear in many different forms – pilot error, operator error, complacency, lack of awareness, poor judgment, bad decision-making, failure to follow procedures. Human error has been cited as a cause or contributing factor in all sorts of disasters and accidents.

Error or action?

Saying that an accident is “caused by human error” is not very helpful. ‘Error’ implies right or wrong, and it’s not the action that should be classified this way, it’s the outcome. Most activities in the workplace are part of the ordinary spectrum of human behaviour. They’re not errors, they’re just actions. But we label those actions after the event, once the outcome is known.

To illustrate, closing a valve in a nuclear reactor to shut it down is a great decision based on sensible human caution if it saves the day, but it’s ‘human error’ if the very same action results in disaster.

Trying to do a good job

Employees don’t generally go to work with the intention of causing harm. They are mostly good people trying to do a good job. They operate within the complexity of organisations with sometimes conflicting goals. People do their best to reconcile any inconsistent goals, eg, operational efficiency versus safety, and to interpret the differing messages provided by the organisation (“Safety comes first, but here’s the production deadline we expect you to achieve.”). They try to achieve success and avoid failure, in an uncertain and confusing work environment.

People aren’t machines

Human beings, like technical systems, have limitations to their capacity and the conditions under which they function best. Operate a mechanical system continuously above its working capacity (eg, too fast or for too long), in a sub-optimal environment (eg, too much dust or heat) and without maintenance and it will eventually fail - just like a human system.

Twenty-twenty hindsight

Human action (or inaction) has played a major role in a large number of famous accidents, and in an even larger number of completely normal, everyday, mundane events. Finding and highlighting people’s ‘mistakes’ explains nothing. Saying what they did, or didn’t do, or should have done, doesn’t explain why they did what they actually did. It doesn’t help to judge a person’s actions - we need to understand their behaviour in light of the situation they found themselves in at the time.

Symptom not cause

If you’re serious about reducing accidents and minimising the consequences of accidents that do occur, the organisation needs to learn from accidents, ‘errors’ and near misses, rather than laying blame on individuals. Assume that they were doing reasonable things given their point of view, their focus of attention at the time, their knowledge and understanding of the situation, their objectives, the objectives of the organisation they work for and the ambiguity that surrounded them. Try to figure out why their behaviours made sense to them at the time.

To truly understand so-called human error, you need to examine the tools, tasks and operating environment (eg, the whole, complex socio-technical system in which people operate). Retraining operators, rewriting procedures, sending out reminders or reprimands and increasing supervision will not help to prevent accidents if the system they operate in sets them up to fail.

*Gary Rowe, CEO, Safety Action Pty Ltd

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