How can I use my brain as PPE? Part 1

By Cristian Sylvestre*
Monday, 13 July, 2009


Can all hazards be eliminated in a practical sense? Of course not, things are always changing one way or another. Human error is part of everyday life, but there has been a reluctance to look at reducing the unintentional mistakes we all make that can get us hurt. It’s much more popular to try and ‘fix’ something.

While ‘blaming’ someone is useless (or worse), doing nothing means you ‘accept’ that the injury was not preventable – fixing something that didn’t contribute to the injury or re-training someone that doesn’t need to be – isn’t going to get you anywhere either.

Of all the examples that come to mind, the most extreme – in terms of fixing something that didn’t contribute to an injury – was of a worker who was walking backwards in the car park telling co-workers a joke. He tripped on a concrete parking divider, fell down and broke his wrist. The employer decided to paint all of the concrete parking dividers yellow. Even the most devoted safety supporters recognised how ridiculous this action was. What good would painting the dividers even shocking pink have done? Unless the worker had eyes on the back of the head, he’s not going to see it, no matter what colour it is.

So, can human error be minimised? Yes, by understanding what causes people to make errors or mistakes – and working on those human factors.

When 20,000 individuals in 300 organisations were asked what causes people to make mistakes, the number one response was ‘rushing’. The top four responses (referred to as ‘states’) were: rushing (40% of the time), fatigue, frustration and complacency. People reported that they were more likely to make unintentional mistakes when they were in one or more of these four states.

When those 20,000 individuals were asked what type of unintentional mistakes they made, the number one response was ‘eyes not on task’. The top four responses (referred to as ‘critical errors’) were: eyes not on task, minds not on task, (being in or moving into the) line of fire and (loss of) balance/traction/grip. People reported that they were most likely to make one or more of the four critical errors whilst in one or more of the four states.

In your own experience, can you think of an injury that you’ve had where you were actually not in at least one of the four states (rushing, tired, frustrated or complacent) looking at what you were doing, thinking about what you were doing, aware of the line of fire and conscious of losing your balance, traction or grip? We’ve asked that question of the 20,000 individuals and they came up with five legitimate scenarios.

What that tells us is that people making unintentional mistakes is a significant factor in people getting injured. It also tells us that the four states and four critical errors are involved in almost 100% of incidents people have.

Have you ever seen an incident report where the corrective action is that the person ‘take more care’ or ‘be more careful’ or ‘pay more attention’? Maybe the person who is reporting the incident is alluding to the fact that the incident may have been caused by an unintentional mistake.

What this research established was that when people are in one or more of the four states, they are most likely to make one or more of the critical errors and thereby, either have an incident or cause themselves an injury. That is, they are more likely to increase their risk of injury. We refer to this as the human ‘state to error’ pattern.

Once you understand and look for this ‘state to error’ pattern in yourself and your co-workers, you’ll see them everywhere. We all make unintentional errors and the pattern is very common.

In the following Safety Solutions eNewsletter, we will present guidelines on how to stop yourself and others from making unintentional mistakes and reduce human error by using your brain as PPE. 

*Cristian Sylvestre, Principal of SafeTrain Pty Ltd.

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