The Risks Associated with Human Error
August 4, 2014 - Kestrel Management
During a recent Ocean Energy Safety Institute (OESI) offshore safety panel, Anadarko Petroleum Director of Engineering and Technology Jim Raney claimed that four out of five major offshore accidents—80%—are caused by human error. He further went on to state that new safety regulations and risk assessments are not sufficient in getting to the root of this issue. In fact, he said that risk assessments may even be detrimental if companies think conducting one is enough and don’t take action on what they learn. Instead, Raney highlighted the importance of creating a corporate safety culture that is supported by leadership and procedures that focus on human factors.
The Human Factor
Human error is a significant source of risk within any organization, one that plays a large role in unintended and sometimes catastrophic events, including occupational and process safety accidents, environmental releases, deviations in product quality, food safety incidents, and medical mistakes. The costs of these errors can be substantial—from financial impacts and damaged corporate reputation, to the potential shutdown of the business, or even loss of human life.
Safety performance within an organization is the combined result of:
- Safety culture
- Operational systems/controls
- Human performance
Safety culture involves leadership, shared beliefs, expectations, attitudes, and opinions about what is acceptable and normal behavior within a specific company. To some degree, culture alone can drive safety performance. Without operational systems and controls, however, the effects of culture are limited and ultimately will not be sustained. Similarly, operational systems/controls (e.g., management processes, systems, and procedures) can improve safety performance, but these effects also are limited without the reinforcement of a strong safety culture. Employee engagement and appropriate and consistent human performance is equally critical. This is especially true within companies with complex operations.
Human Performance Reliability Approach
Companies rely on a variety of engineered and administrative controls to manage employee and contractor behavior. From an operational perspective, these controls include organizational culture, policies, procedures and practices, maintenance programs, employee selection and training, supervision, working conditions, etc. Unintended events occur when there is a weakness or failure in one or more of these controls. The challenge is to know which of the controls are working well, which need improvement, and which are missing.
Human Performance Reliability (HPR) helps companies characterize and classify errors, and then identify, understand, and ultimately manage the factors that contribute to human error to prevent future incidents and accidents through the following approach:
- Develop an inventory and understanding of current operational controls (e.g., policies, procedures, practices, maintenance programs, employee selection and training, supervision, working conditions).
- Review existing incident reports and identify the multiple factors that may be contributing to human error.
- Identify the specific operational controls that are contributing to human error.
- Improve and/or develop the controls necessary to strengthen the barriers to and reduce the likelihood of recurring human error.
Framework for Ongoing Improvement
All of these controls must be organized into a management system for a company to be able to achieve their operational and management objectives. A safety management system forms the basis for continual business improvement and is the key to any successful enterprise risk management program.
Employing a disciplined process, like HPR, to collect and analyze incident data and then create implementable improvements, is a vital component of management system implementation. Integrating HPR data into an effective management system improves risk management and provides the framework for developing predictive monitoring capabilities and achieving continual operational improvement. In fact, reliable and effective regulatory compliance and incident response are commonly outcomes of consistent and reliable implementation of a management system.
Submitted by: A.W. Armstrong