When a workplace accident occurs, we often focus attention on the individual and the errors he or she made. But that’s not the only way to look at workplace accidents and human error.
You can look at human errors that lead to workplace accidents in one of two ways, says professor of psychology Dr. James Reason in the British Medical Journal, the person approach or the system approach. According to Dr. Reason:
- The person approach focuses on the errors of individuals, blaming them for forgetfulness, inattention, or moral weakness. The emphasis is on unsafe acts.
- The system approach concentrates on the conditions under which individuals work and tries to build defenses to avert errors or mitigate their effects.
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The person approach emphasizes unsafe acts resulting from slips, lapses, fumbles, mistakes, and violations of safety rules. The person approach blames the errors that lead to accidents on human failings such as forgetfulness, inattention, poor motivation, carelessness, negligence, and recklessness.
“Naturally enough,” Reason says, “the associated countermeasures are directed mainly at reducing unwanted variability in human behaviour.”
A serious weakness of the person approach, Reason believes, is that focusing on the individual origins of error isolates unsafe acts from their system context. “As a result,” he says, “two important features of human error tend to be overlooked:
- “It is often the best people who make the worst mistakes—error is not the monopoly of an unfortunate few.”
- “Far from being random, mishaps tend to fall into recurrent patterns. The same set of circumstances can provoke similar errors, regardless of the people involved. The pursuit of greater safety is seriously impeded by an approach that does not seek out and remove the error provoking properties within the system at large.”
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The system approach, on the other hand, recognizes that humans are fallible and errors are to be expected, even in the best organizations. “Errors are seen as consequences rather than causes, having their origins not so much in the perversity of human nature as in ‘upstream’ systemic factors,” says Reason. “These include recurrent error traps in the workplace and the organisational processes that give rise to them.”
Preventing workplace accidents under the system approach is based on the assumption that though you can’t change the human condition, you can change the conditions under which employees work.
“A central idea is that of system defences,” Reason asserts. “All hazardous technologies possess barriers and safeguards. When an adverse event occurs, the important issue is not who blundered, but how and why the defences failed.”
Tomorrow, we’ll continue to examine human error and workplace accidents, featuring three common “error traps” identified by a renowned American safety expert whose name you’ll probably recognize.