Tag Archives: human error

Just culture: Who are we really afraid of?

When we think about just culture, we usually think about accidents and incidents, associated ‘honest mistakes’ and ‘negligence’ (by whatever name), as well as official responses to these, at company and judicial level. The notion of just culture is driven partly by fear; fear of being judged and blamed, especially fear of being blamed unfairly. The fear is felt most strongly by operational staff, who are at the sharp end of organisations and have sometimes faced disciplinary … Continue Reading ››

Bad Seamanship: Is that so?

pexels-photo-largePicture the scene: The car carrier Hoegh Osaka has just departed from the port of Southampton, at which point the master calls up the mate and says that the ship did “not feel right”, to which the mate in charge at the loading computer replies “I am working on it”. Soon afterwards the vessel runs aground and eventually capsizes, leading to a catastrophic accident off the port approaches. The investigation into the case finds that the vessel was … Continue Reading ››

Is ‘human error’ the handicap of human factors? A discussion among human factors specialists.

DSCN0484Following most major accidents, one phrase is almost guaranteed to headline in the popular press: ‘human error’. The concept is also popular in the ergonomics and human factors (EHF) discipline and profession; it is probably among the most profitable in terms of research and consultancy dollars. While seductively simple to the layperson, it comes with a variety of meanings and interpretations with respect to causation and culpability. With its evocative associations, synonyms, and position in our own … Continue Reading ››

Is it 1947 yet?

broken_iceNeither Lieutenant Nathan Poloski’s body, nor his F/A-18 Hornet were ever found in waters almost three miles deep. All that was located in the Western Pacific after his fighter jet collided with another from the same aircraft carrier were his helmet and some pieces of debris. The pilot of the other jet ejected safely and was rescued shortly after. The Navy accident report, all of eight pages long, was acquired by the New York Times under a Freedom … Continue Reading ››

Resilience and the Pembroke refinery explosion

Chevron_pembroke_refPembroke Refinery is an oil processing facility on the Milford Haven Waterway, in Wales. It was the site of a multiple-fatality explosion in 2011, and the grounding of the Sea Empress in 1996, releasing a major oil spill into Pembrokeshire Coast National Park. Prior to both of these events, Pembroke Refinery made national headlines with another explosion and fire, fortunately non-fatal. Early on the morning of 24th July, 1994, there was a dry electrical storm raging above the … Continue Reading ››

The use and abuse of ‘human error’

"Oh my God. I told those guys at safety that it was dangerous and one day we would lose concentration and pay for it. I already told those guys at safety that it was very dangerous! We are human and this can happen to us. This curve is inhuman!" These are the distressed words of the injured train driver moments after the train derailment in Santiago de Compostela, northern Spain on 25 July 2013. The driver can be heard pleading in sorrow, hoping for the safety … Continue Reading ››

A kitchen safety fable

Exif_JPEG_PICTUREOnce upon a time researchers found that many injuries in the home were due to kettles being left to boil dry.  Analysis of the accidents, that often lead to burns and fires, revealed that there were very small instances of malfunction of the kettles or the stoves and indeed the water usually behaved appropriately too.  Investigators have found that an unsafe act (leaving the kettle unsupervised) was the cause of the injuries in 88% of the cases. The success story … Continue Reading ››

What about idiots?

file0001612800212[1]In early 2013 a group of Australian miners choreographed and performed their rendition of the ‘Harlem Shake’, a music video that has stimulated 100s of similar dances to be uploaded to YouTube. Deep underground, the miners dressed down some of their PPE and free styled in front of the camera. When Barminco, the operator of the mine, learned about the dance venture, they sent a dismissal letter to 15 workers involved in the making of the video. … Continue Reading ››

Humans – The strongest link

file000155942936The typical focus in safety is that the human being is our weakest link in safety. But they are indeed the strongest: naturally equipped to deal with risks dynamically, and with incredible risk skills... We just need to unleash that capability... The traditional focus on the human, in the context of safety, is that the human being is the weak link, the hazard, the ‘error maker’. A safety conference where the human being is not pointed out as the key … Continue Reading ››

What happened to creativity?

file7491250647364The other day I was fortunate to come across a quote by Sir Ken Robinson. "If you're not prepared to be wrong, you'll never come up with anything original". Even better, there was a link to his talk Ken Robinson says schools kill creativity. His contention is that creativity is now as important in education of children as literacy and that it should be treated with the same status. Listening to his talk I was struck by how … Continue Reading ››