Troubleshooting Human Error to Ensure Safety

Paul Chamberlain Columns, Safety Corner, Spring 2020 Columns

What is human error? A human error is the outcome of an action that does not produce results as intended. It can be summed up by saying things did not go as planned. The 6P Rule (Proper Prior Planning Prevents Poor Performance) can go a long way to preventing a human error, but there is still that human factor. James Reason, author of 12 Principles of Error Management and co-originator of the widely accepted Swiss cheese model of accident causation, states, “Human error is a consequence, not a cause. Errors are shaped by upstream workplace and organizational factors… Only by understanding the context of the error can we hope to limit its reoccurrence.” Human beings are fallible; they make mistakes — and those mistakes are usually caused by only a few factors.

While resolving an issue or troubleshooting a problem, many traps present themselves. These traps can contribute to a potential incident. Identifying these traps and mitigating them will prevent the incident. This article looks at some of the common traps encountered when performing any task, whether routine or troubleshooting.

Working Under Pressure

When employees rush to complete a project or a task, they can have a lapse of judgement. Troubleshooting a component that failed and repairing or replacing it to reenergize a critical system is a prime example of what can occur under time pressure. Another example is an outage window prior to energization of new components. Skipping steps, improper communication, and missing warning signs are just a few of the issues that can occur when rushing in response to internal or external forces.

Time pressure can be internal, such as a need to get home at the end of the day or scheduling conflicts with the individual’s personal life. For example, an employee’s son is pitching his first high school baseball game that evening, but the employee’s work is unfinished. To make it to the game for the first pitch, the employee completes his tasks for the day quickly. While not intentional, rushing through the work can produce mistakes leading to incorrectly operated equipment, potential injuries, or worse.

External time pressure can occur when a prime contractor, boss, or peer is pressuring another employee or subcontractor to complete the work quickly. Maybe they need to move on to another location or task, or maybe there is only a limited outage window impacted by some external force (e.g., other contractors eating up outage time).

Be aware of Mondays and Fridays. On Mondays, some employees may be not be fully recovered from a full weekend. This can cause mental lapses in judgement due to being tired or not fully engaged in the work. On Fridays, they may be in a rush to get out the door and start an exciting weekend, causing mental disengagement with the task. In addition, mental disengagement applies after any prolonged absence from work, such as before and after long weekends, vacations, lay-offs, etc.

No matter where the need to rush originates, slow down and realize this time pressure can lead to a mistake. It is quicker to do something right once than to do it wrong and have to do it a second time.

Not Paying Attention to the Task

Mental and physical distraction can lead to a lapse of judgement or a missed step. When doing something critical that requires intense awareness, keep distractions to a minimum. In this technological age, cellular phones are a major distraction. Make it a habit to power them down or put them elsewhere and on vibrate whenever doing something critical. Cell phones are a good example of mental and physical distraction.

Other distractions can include a change in work shift, which can contribute to tiredness and dulled senses. Drastically changing weather can also be a distraction. Outside the work environment, employees may be distracted by trouble at home, kids getting bad grades, money issues, and so on. All of these can be detrimental in the work environment.

Ensure distractions are minimized during any task where improper action can cause significant consequences. Many traps can be mitigated using a few simple tricks and tools to prevent employee errors and incidents.

Poor Communication

Ensuring a message is sent and received properly is critical. Use the phonetic alphabet and numerals when communicating equipment identifications or other nomenclature. This prevents peers and other employees from going to the wrong equipment or using incorrect or misheard settings.

It is always a good idea to use three-part communication when performing critical tasks. Three-part communication consists of:

  1. A sender saying a direction or information.
  2. A receiver repeating the information verbatim.
  3. The sender acknowledging that the information is correct.

If the information is repeated back incorrectly, the sender states the information is incorrect and repeats step #1. Using three-part communication ensures the sent message was received.

As the sender of information, ensure the receiver truly understands what is necessary. Over-communicate the steps needed and the results expected. Write it down and give notes to the receiver. This ensures complete understanding, whether between members of a work crew or during turnover from one work group to another.

As a receiver of information, it is important to get all the information needed to successfully complete the task. This means question everything. Question why certain test procedures are used, question why a lockout was performed and by whom and when. Ensure the big picture is achieved so all aspects of the job are understood.

Losing Your Place

Place-keeping marks the completed steps in a critical procedure or work document so steps are not accidentally omitted or repeated. Place-keeping identifies the last step completed when suspending performance of a procedure. Before recommencing the work, conduct a thorough re-review of the procedure.

Physical Barriers and Visible Cues

Flagging involves highlighting a component to improve the chances of performing actions on the correct component. Operational barriers mark or cover components not to be worked on or manipulated during an evolution. Operational barriers and flagging are particularly helpful when several similar components are in close proximity to those affected by the work activity. Research indicates incidents can often be attributed to an individual starting an activity on one component, taking a break or being otherwise distracted, and returning only to perform manipulations on the wrong component.

Coaching and Accepting Coaching

It’s human nature to get distracted or complacent on the job and to deviate from performing the prescribed safe operating procedure. In reality, many accidents occur when well-trained employees working in a well-engineered environment do something they shouldn’t have or fail to do something they should have. Identify high-risk tasks and best­practice behaviors in those situations and coach all employees on how to maintain mindfulness and consistently demonstrate those best-practice behaviors. Coach employees on:

  • How to speak up when they see a co-worker (or boss) engaging in unsafe behavior
  • How to correct that behavior without creating conflict
  • How to discuss and learn from near-miss events
  • How to plan and run safety meetings that engage employees and promote safety awareness
  • How to function as safety leaders by watching out for themselves and others as they go about their work

Peer coaching and checking are another way to mitigate incident potential. When doing a complex task — or one that could result in bad things happening if the wrong thing is done to the wrong object at the wrong time — use your peers. Get help to ensure the task is performed correctly. Two brains and two sets of eyes are always better than one. Have a peer read the procedure while the performer completes the procedure, and always ensure three-way communication is conducted during this process. Have a peer double-check your calculations prior to submitting them. Have a peer check your grounds prior to beginning the work. There are many ways to use a peer who is either working directly or indirectly with the performer of the task to ensure the task is completed safely.

The Big Picture

All of the previous human conditions contribute to an employee or peer making an error. The first and most effective means of reducing errors is to be fully engaged in the task at hand. Identify those things that may be a distraction or contribute to a mistake and eliminate those items from the work task. Many accidents occur because the employee continued blindly on in a task and did not heed any of the little warning signs. When something doesn’t seem right, stop, take a step back to reevaluate, and ask questions of the team performing the work. Get a peer to help. Find out why things aren’t right and heed those warnings. Be cognizant of any internal problems, acknowledge they may affect the work, and discuss with fellow workers. This will help minimize the possibility of a problem.

Simple, everyday tools can help mitigate human fallibility. Handwritten notes are the old-school, tried-and-true method. Laptops and scheduling programs are newer methodologies. Make notes either on paper or electronically so things won’t be forgotten. Come up with plans and procedures for the task and write them down step by step before the work begins. This helps ensure the right skills, tools, equipment, and personnel are present for the work. Pre-job briefings are an effective means of documenting and communicating steps and hazards on the job. The more complex or unfamiliar a task is, the more complex the pre-job briefing must be. Ensure all personnel affected by the task attend the pre-job briefing. Include other contractors not directly involved in the scope of work who are in or near the work area where the task is to be performed.

Conclusion

Being aware of all contributing factors — and planning for their mitigation — helps make the work environment safer for all. Everyone makes mistakes, but there are ways to identify and minimize the factors that contribute to those mistakes.

Paul Chamberlain has been the Safety Manager for American Electrical Testing Co., LLC since 2009. He has been in the safety field for the past 21 years, working for various companies and in various industries. He received a BS in safety and environmental protection from Massachusetts Maritime Academy.