Incident investigation and analysis helps us to identify and correct the immediate and underlying causes that contributed to an incident and so prevent its future recurrence.
How do we analyze the Incidents?
Incidents can be analyzed in three steps:
Identify the chain of events from the cause to the undesirable consequences;
Identify the defenses/ barriers that should have stopped the chain of events;
Identify the cause for failure of each of the barriers.
The immediate contributory cause of the incident is the human errors / human failures. Mistakes, shortcuts or violations are types of behavior that may lead to incidents. They are the result of irresponsible or outrageous intentions. These intentions are preconditions that enable an incident to happen. These preconditions, in turn, are affected by the underlying causes. These underlying causes can be found in the influencing environment which can be studied as latent failures. Latent failures are usually hidden within an organization until they are triggered by an event resulting in serious consequences. Latent failures are typically failures that include poor designing of plant and equipment, ineffective communication, inadequate training, poor supervision, poor housekeeping, improper maintenance, organizational errors, poor safety culture, etc..
Investigating an accident involving human failure should look into the causes and contributing factors to understand why the human failures occurred. Finding out both the immediate and the underlying causes of an accident is the key to preventing similar accidents. Typical examples of immediate causes and contributing factors for human failures can be discussed as:
Job Factors:
Poor design of equipment and machinery
Continuous interruptions and disturbances
Unclear or inadequate instructions
Overload of work
Noisy and unpleasant work environment
Improperly maintained equipment
Personal factors
Lack of skill and competence
Poor judgment
Inadequate risk management
Violation of rules
Distraction
Fatigue and tiredness
Individual medical issues
Organization factors
Improper response to previous accidents
Poor safety culture
Inadequate training to the workers
Lack of management commitment
Inadequate supervision
Inadequate risk management
Importance of Preventing Human Failures
The most important factors to be considered while investigating accidents:
Identifying the reason WHY the incident could happen
How to prevent its recurrence
Learning from it and applying the lessons for similar situations
Most of the large industrial incidents, like the Bhopal gas tragedy, Flixborough, Chernobyl nuclear disaster have some common aspects:
Most of the incidents and accidents have occurred due to human failures. Also, other theories state that human Failures account for 50-90% of accidents. Certainly, it is difficult to prevent human failures in an authentic /sustainable way.
It is therefore very important for managers and HSE professionals to look and identify human failures, why they happened and how they can be prevented in a sustainable way.
The incident investigation should ensure in
Finding deeper causes of the accidents.
Finding better ways for the management to get control over human failures.
Employing the methods for improving human behaviors.
Bringing improvements not only in the area of an accident investigation but to the whole organization.
The Prevention of Human Errors and failures
It is said that human error causes up 80% of all accidents and if we eliminate human errors or prevent them, we can successfully prevent most of the accidents. Humans will always make mistakes and triggered by some latent errors or failures and resulting the accidents to happen. These latent errors are the root cause of most accidents. Thereby, the most important way to reduce human error and prevent accidents is through effective management such that safety is considered the utmost priority.
List of ways to reduce human errors at the workplace:
Motivational Campaigns for workers
There should be a system where some kind of rewards are offered for the workers following safety regulations, operating in a safe manner, spotting the hazards. Workers should be encouraged to repeat desired behavior by offering positive consequences for said behavior and at the same time letting them know the negative consequences for unsafe behavior. Studies show that employee satisfaction tends to rise when employees are recognized and appreciated by management that can actually make a big difference.
Implementing Disciplinary actions
It is essential to understand the importance of discipline in safety and its role in an overall system for accident prevention. Safety program should be implemented in such a way that the workers should Study and follow all safe practices while at work. They should coordinate and cooperate with all other employees in the workplace in preventing injuries and illnesses. Every industrial injury or occupational illness has to be reported promptly to their supervisor as a principle of accident prevention in their daily work.
Safety Audits
Safety audits provide a framework to better understand some of the common human Factors that can ensure regular checks on unsafe behavioral patterns in humans and recommend the precautions to be taken and corrective actions. Conducting a workplace safety audit is the most extensive approach for strengthening safe behaviors while providing corrective actions.
Conducting Behavior Based Training.
Behavior-Based Training is very important in reducing human errors and hence accidents. Training given should be well planned and systematically designed. Everybody must be familiar with the policies, procedures, processes and made aware of the risks involved and how their actions affect safety. Training should be conducted using all necessary methods and strategies that can effectively improve safety performance. Individual performance checks and evaluations should be done to identify critical behaviors. Such type of trainings helps us to learn why human errors occur and how to correct them before they create problems.
Redesign the Job task, the Equipment, or the Procedures.
The main way to reduce accidents caused by human errors is to redesign the job task or the Procedures. A simply designed job will reduce confusion, stress and mistakes are less likely to occur. Procedures are very important and should be well trained to the workers which should be clear, precise, and easy to read. They should be in an easily understandable manner by the workers.
So, preventing human errors is recognized as a major contributor to safety performance and reliability.
“ An error does not become a mistake until you refuse to correct it”.
No comments:
Post a Comment