In light of the tragedy in Greece this week, I think it is time to share this video from Lund University’s College of Human Factors Engineering again. Be sure to check out all of Johan Bergström’s videos on YouTube.
A term in HFE seldom gets mentioned during accident investigations, as most will say it, “muddies the water” in the investigation. But the space between “technical failure” and “human error” is oftentimes found to be an “error trap.” An Error trap is best defined as “a situation where the circumstances in combination with human cognitive limitations make errors more likely.” (Highley)
I like to redefine this because oftentimes, the same error is made, but with vastly different consequences. And because these errors resulted in a DESIRED OUTCOME (saved time, made the task easier, took less $, etc.), it raises the probability that the person may CONSCIOUSLY DECIDE to make that error again, which brings into question… is it an error when it is done CONSCIOUSLY for reasons that made sense to the human at the time. This is the bridge to Behavior Based Safety. And this takes me back to Reason’s Human Failure Model of Errors, Mistakes, and Violations.
The critical role of any Behavior Based Safety Observation process is to IDENTIFY deviant behaviors, that we call “unsafe”. But to identify behaviors that deviate from the norm, we must first establish the norm. We have traditionally done this with formal written procedures, safety rules, etc. which we then train workers on at some established frequency, AND knowledge of that training is VERIFIED by some means. We then should examine the workplace for “error traps” that could lead the worker(s) to make an HONEST error or mistake. Identifying and correcting these traps will only support and solidify the written procedures.
We have just done Human Factors Engineering on the most basic level. Of course, how we fix the error traps gets deeper into HFE and that discussion is for a later time.