Investigating Human Error: incidents, accidents, and complex systems
Tuesday 12th September 2017
From the archive: Just so you know, this article is more than 3 years old.
But investigations often fall short when they get to the difficult issue of human error, seeing it as a principal cause of accidents.
Psychologist Barry Strauch argues such an approach misses the point: no investigation can be considered to be complete until those leading it have understood why people acted as they did.
In the second edition of his book, Strauch explores human error from the investigator's point of view. His focus is transport accidents, including air and rail crashes, but the findings are relevant to other complex system tasks such as running a power station control room or carrying out a surgical procedure in an operating theatre.
There are four main sections: section 1 "errors and complex systems" sets the scene, then "antecedents" delves into latent factors such as the equipment, operator and corporate culture. The third section reviews the various sources of data on which investigators can draw, while the fourth ("issues") includes chapters on "maintenance and inspection", "situation awareness and decision making" (important because at one stage "loss of situational awareness" became the new catch-all accident cause"), "automation" and "final thoughts". This last section also includes an extended case study based on the crash of an Asiana Airlines Boeing 777 at San Francisco in July 2013 (the burnt-out and tail-less aircraft shown on the front cover).
The book has a strong structure that aids understanding and it gives enough detail so that the reader understands the complexity of the issues involved.
The theory is there too and helps the reader to understand the facts of what happened. If you want to delve into the sources, they are copiously referenced and indexed, and each chapter has an introduction and summary so that you can see at a glance what it covers. Almost all the chapters include a practical checklist for the investigator: a useful feature.
Like systems, no investigator is perfect. As investigators we hope to show objectivity, attention to detail and painstaking persistence, but exercising these positive attributes sometimes leads us to lose touch with the human side of what we are investigating: empathy, tact and consideration are important qualities for the effective investigator.
Strauch brings together all these qualities in this book: he is technically thorough, but never loses sight of the human cost of accidents. He rightly presents being an investigator as a great calling and gives hope that future tragedies may be prevented -- if only we avoid short cuts as we seek to learn from what's gone wrong. Highly recommended, and excellent value at the price.
Andragogy, digibesity, people-centred safety; even to those with English as their first language, the global gathering of OSH practitioners in Singapore offered some potentially novel terms.Almost 3,500 delegates from more than 80 countries attended the 21st World Congress on Safety and Health at Work in Singapore’s Marina Bay Sands Convention Centre from 3 to 6 September.
New figures which begin to quantify this stark truth were revealed at the World Congress on Safety and Health at Work in Singapore (September 2017), a triennial gathering where leading organisations for safety and health connect with ministers, policymakers and some of the world’s largest corporations.
Unusually among the leaders interviewed for this magazine, Derran Williams CMIOSH has no one reporting to him. Yet he is responsible for overseeing the safety and health of hundreds of thousands of workers in massive infrastructure projects from road schemes to power stations across eastern Europe and beyond.As associate director and senior health and safety adviser at the London-based European Bank for Reconstruction and Development (EBRD), Williams has to verify that the standards of protection are acceptable on the schemes the bank funds.
Rating: Readers outside the US will have to accept that Reese’s book is aimed at that market so its regulatory references are to the Occupational Safety and Health Administration and the studies it cites are mainly from the US.
The new advice, developed jointly by Public Health England (PHE) and health and wellbeing services provider Healthy Working Futures (formerly the Fit For Work Team), aims to help employers promote good health. The guidance includes information on carrying out a workplace health needs assessment (HNA) – a series of questions that staff answer anonymously. Businesses can use the findings to tailor activities to improve health and wellbeing.
Sellafield’s nuclear decommissioning and reprocessing site on the Cumbrian coast is home to one of the largest and most complex construction projects under way in the UK.The site is undergoing a 100-year-long programme to replace the original treatment and storage facilities, which have deteriorated since construction at the start of the cold war in the late 1940s and 1950s (see our feature in November 2016’s IOSH Magazine, bit.ly/2wLvqSN Sellafield, nuclear decommissioning).