Human factor: an expression used in the anal
ysis of an accident or incident at work. We all have in mind these pictures on the web showing errors. Whatever the cause, human behavior can play a significant role. So is it possible to coach it? Is it possible to reduce or even eliminate risks probability? Yes, here are some examples of good practices.
What is the "Human Factor"?
This expression is used to describe "human behavior", particularly in the context of analyzing an accident or incident at work.
Indeed, it is taken into account in most analysis techniques (Fishbone diagram, Causal Tree Analysis, etc.) because it is almost always part of the origins of work accidents or incidents. But, whether its role is minor or major, can we coach the human factor so as to reduce or even eliminate the probability of occurrence and / or severity of these accidents or incidents
Why does it happen?
The causes are ultimately simple. They could include in particular the lack of time, a routine and usual activity, a lack of clarity in the organization (duties, planning ...), a time-consuming and difficult activity requiring a high concentration, a complex task performed by several actors, frequent interruptions ...
We’ve all ever made a mistake because we were thinking about something else at the same time.
For example, overflow our glass of water because we are absorbed by the latest television news. Or even worse, have you ever felt this horrible sensation after a few minutes of driving where you realize you have no memory of the last kilometers traveled? "I already got here? But how did I do that! "
Thinking about it, you will realize that this ride has become a routine and that during these few minutes you were completely lost in your mind, often focusing on your daily concerns such as the shopping that needs to be done, the folder that needs to be submitted.
Tests highlighting these types of human errors have been developed, such as the test below that I encourage you to take:
So, what method to apply to coach it?
A set of practices can be implemented within a company to prepare the human factor. In order for these practices to be effective, they must be implemented at each stage of an intervention and include all participants involved.
1. Run a beforehand debrief
It aims to prepare the intervention at the individual and collective level and to anticipate any difficulties that may be encountered. It must take place before starting the action or following a significant interruption (as during a succession for example).
It must address the objectives of this intervention and consider the risks inherent to it. For this, situations that could lead to errors shall be anticipated and ways to prevent / avoid them shall be planned.
But above all, it must be based on feedback from similar interventions that have already been done, so as to remain aware of what could have been forgotten.
2. Anticipate downtime
These downtimes shall not last more than a minute and shall not look like a waste of time. On the contrary, they aim to avoid all errors related to precipitation but more importantly to ensure the safety of the participant.
They shall occur as often as the participant needs them and at least before starting / going back to work or following an unpredicted event.
There are multiple objectives, such as to detect the risks inherent to the working environment, to anticipate a lack or a material mistake, to issue a progress report, etc.
3. Secure communication
This step may seem trivial, but it is essential to check that all participants have understood the information and have correctly associated with an action to achieve. The information must be clear, complete and targeted and must be broadcasted according to a pre established communication protocol.
For example, two participants positioned on either side of a wall, having no eye contact and having to cut a cable running through the wall. The first participant with the electrical diagram notifies to the second that the wire on the right must be cut. The action is performed by the second participant. Unfortunately, because of the mirror effect, the wrong cable was cut. Indeed, the right of the order giver corresponds to the left of the performer on the other side of the wall.
One of the basic techniques to avoid this error is to have the performer repeat the order aloud. The order giver can then easily make sure that the information has been understood and spot any possible error in its communication.
4. Perform cross checks
Unlike a posteriori verification which ascertains the achievement of the wanted results but does not ensure success at the first test, cross check is performed upstream to guarantee success and result from the first time.
Cross checks are not systematic. They are made in a framework for intervention that could lead to serious consequences.
Very often, cross check consists of three stages. The performer verbally explains to one of his counterparts what he has to do and how he intends to do it. This counterpart makes sure what has been explained to him makes sense (method, material, …) and gives his approval if everything follows standards. The performer can perform the task only after obtaining the counterpart’s approval to do so.
Before starting, the participant makes sure that he is working on the right element.
The best method consists of two steps. The participant reads aloud the particular element’s name written on the intervention request while following what’s written with his finger. Then he reads aloud the name written on the element following what’s written with his finger.
This method may sound ludicrous, yet it has proved its worth. By forcing the participant to read aloud and follow what’s written with his finger, we prevent the risk of confusion between two elements. For example, between:
“BKG machine" and "BGK machine”
He is unconsciously pushed to reinforce the attention he pays to the intervention he has to perform.
6. Run an after-action debrief
This debriefing is essential. It allows to get feedback for future interventions. For this, it is essential that all participants take part in sharing all the information related to the intervention to their manager, who will then trace them. The gaps and problems encountered as well as the curative solutions implemented must therefore be addressed, as well as the means of prevention that can be envisioned so as to avoid these for a similar next intervention.
The aim is to update procedures if needed, to update the risk analysis, to modify the site organization (modification of the phasing stages of a project for example), to change the planned material, etc.
Get a team to adhere, my experience
I had the opportunity to implement this methodology on a site with a newly formed team. The hardest part is to get them to adhere… It's human to feel stupid reading aloud and following with your finger as an adult. Most operational staff are not used to being consulted at the end of an intervention to share their feelings and to give their recommendations. But most importantly, we do not like to report difficulties that we have encountered or mistakes we’ve made, for fear of the negative judgment that may result.
So it’s really hard to get a team to agree on a new method with so many brakes (the list is not exhaustive). I was quite skeptical myself about this method even though I should have been the first to be convinced because of the position I held.
Yet it is clear that the results are there.
Indeed, by approaching the first interventions without requiring a faultless involvement of each participant, but rather motivating them to try, the members of my team got fully engaged progressively. Through concrete cases, they noted that these practices worked and so adhered to the method.
If you plan on working on the human factor by following a method like this, I recommend you proceed in stages to gradually get your teams to agree on an operating mode that’s not widely used in business. The results will be quickly observed on the human level as well as the economic level, without generating additional costs. This method has been used for many years, especially in large groups like EDF.