Variations that exist within system processes may be putting workers on a path to making poor decisions while performing their work and invariably compromising their safety. That’s an assertion made by Scott Gaddis, the Health and Safety Practice Leader for Intelex Technologies and a 25-year veteran of environmental health and safety leadership and management.
It’s important to tighten process methodologies to ensure there’s little room for interpretation by workers that forms bad safety habits. In his recently published Intelex Insight Report, entitled, Unleash a Better Safety Culture by Controlling Process Variability, Gaddis notes that, in many incidents where a worker performs an unsafe act, the decision that often led to err was likely influenced by other uncontrolled variables residing within the work system itself.
Dan Peterson, in his book, Human Error Reduction and Safety Management, writes that “Human error is involved in every accident and there are many reasons behind this behavior.” Peterson goes on to say that “When incidents occur, it’s the result of systems failure AND human error.” The decision by a worker who chooses to do an unsafe act is often directly linked to the work system where he or she resides.
It’s a matter of removing the possibilities for deviation from safe processes and behaviors. By way of example, Gaddis cites in his report a workplace incident he investigated several years ago where a worker was killed while performing a task on jammed equipment that had not been isolated from its energy sources. The worker had reached in to clear a machine jam and, while doing so, caused the equipment to resume operation once the jammed product was dislodged, and resulted in him being crushed.
In reviewing the event and analyzing the scene and equipment involved, Gaddis says the hazards were clearly evident, the facility’s energy-isolation procedure was complete, and records indicated the employee had been sufficiently trained. So why did the incident happen? During employee interviews and reviews of past maintenance and downtime reports, planned inspections and training records, Gaddis discovered a new emerging picture of uncontrolled variability in the work system and it had created an environment for inevitable human error. The employee was simply emulating behaviors of a work system that supported such risk taking, he says.
Gaining control of the work system begins by understanding where variability exists in processes. Gaddis says his investigation of the fatality revealed latent errors dating back years prior. The machine had been poorly designed and inadequately guarded. Training had been performed and procedures written, but the capability development plan lacked a quantifiable method for measuring success. The preventive and reactive maintenance plan was weak and there existed a lack of management discipline and control. The organization simply allowed too many variables to reside in the work system, creating the very real potential for catastrophic loss when the worker accepted the deviant errors as the norm and made the fatal decision to err, which cost him his life.
It is important to understand is that when deviance occurs in one process, it is likely to impact others. To mitigate such errors, a systems approach is warranted with the goal of building process robustness.
Read more about the risks of process variation and its potential impact on worker safety in this recently published Intelex Insight Report. You can download it here: