Are directors and managers human and do they make errors?
8th December 2015
The “Clamour for Consequences” and “Fair and Just Culture” have been the subject of recent blogs and a strong part of the discussion around enabling excellence in Health & Safety. The recent news update regarding a tragic amusement park incident caused me to pause again and think about the language we use when discussing the findings from incidents and the impression those words can give.
In this instance, the headline read “…ride crash due to human error” and it went on to explain that no technical faults with the ride were identified. A reader of the article is likely to know little of the specific facts pertaining to this case, but even such a short news article can be insightful regarding the leadership behaviours we exhibit. The story goes on to tell us that the standard HR procedure had been enacted, and appropriate action taken, in dealing with those staff whose errors caused the crash.
After seeing this article, I reflected on the use of the phrase “human error” and how it is applied to incidents. Human error is generally accepted to arise from factors that relate to the person, the task they are conducting and the overall organisation that they sit within.
The person and the job factors often relate to the immediate and underlying causes we more commonly identify in our investigations. The most challenging piece for any business is to look beyond those and really identify the organisational factors. Sometimes these are mistakenly believed to be purely about the physical work environment. This is NOT the case.
To illustrate some of these organisational factors, I was recently at a different park where families go for a fun day out. It was a busy day and there were the dreaded queues! I had a 90 minute wait, with my two young sons to get on a 3 minute ride. During that period, I observed a young worker coping in the most difficult circumstances. In the timeframe we were there, she had no physical assistance to manage the safe operation of the ride. She assisted customers on and off; there were three different queues, a safety briefing with every ride, crowd control, some carriages out of use, screaming children, frustrated parents, no colleague to assist or rotate the job, etc, etc. Under these intense conditions, she appeared in control and calm!
In this case, organisational factors, which are known to have the greatest impact on behaviour, would include:
- pressure of work (the pace dictated by the 3 minute ride, 90 minute queue and the extra people allowed through on other queues),
- lack of supervision to deal with issues if they arise,
- significant responsibility placed on a young person, and
- no opportunity to take a break, relax and then refocus.
Having some insight into the demands placed on this young worker, if there been an incident in this example, would we have felt differently about the operative? Was it their human error that primarily contributed to the incident? Did the operative create the very challenging work environment I observed? Was it their human error, i.e. their behaviour or that of the directors and managers of the organisation, who set the staffing levels, job rotation, breaks, number of queue options, etc?
In the example I witnessed, it seemed to me that the operative had potentially been set up to fail and the system of work was intolerant to errors that might occur.
To go back to the title of this blog, anyone can make an error, regardless of which role they hold within the organisation or supply chain and that is all part of being human! From a communication perspective, we should review the fact that the phrase “human error” appears as an accusation against the level of attention of the front line employee. The errors of directors and managers are typically far more significant and may often lie hidden until a catastrophic event unfolds.
From my own experience, the headline, as reported, is highly likely to have a negative impact both on morale and the development of a strong Health & Safety culture.
If you would like to understand more about human factors, human error and positive communication for Health & Safety, please get in touch.