Human Error — The elephant in the room
It was Human Error! This term is intuitively recognizable to most safety professionals across various industries and work domains. In shipping, the accident statistics published by insurance companies tell a story of human error playing a part in up to 96% of all claims. But what does human error actually mean? What can we do about it? Where is the maritime industry heading with this? What risks are we running if Human Factors are continued to be neglected? This blog post will seek to shed some light on these questions.
What is Human Error even?
Up until World War II the concept of Human Error was mainly a topic researched from a behavioral psychology angle, with the fundamental assumption that the features of the world were somewhat fixed. Human Error simply happened because people did not behave appropriately in relation to the fixed rules, and improving human performance was for the behaviorists a matter of making people adhere and fit.
While the behavior-based safety paradigm remained intact and does to this day, something happened just after World War II that set off the development of a different paradigm that has continued to develop ever since. Research into pilot error in fighter plane cockpits resulted in conclusions very different from those pointing to the errors of individuals as the cause of accidents. The researchers concluded that “human error” was rather a symptom of poor design of the cockpit environment, which as a consequence made the interaction between pilot and equipment result in occasional failure.
This new focus on the interplay between people and the features of their environment, even social, has since led to a number of theories, methods, and arguments — some even proposing that Human Error as a concept is an analytical dead-end. Leaving semantics aside, the fairly common denominator in modern safety thinking is that Human Error is not a problem that should be attributed to the individual alone (opposed to, e.g., the old-fashioned strict behavior-based safety approach). In fact, more researchers now highlight the frontline personnel as a vital part of the solution to a lot of the imperfections that work systems has, e.g., by stopping a dangerous situation from unfolding into a full-blown accident — which was concluded from a recent extensive study of maritime near-miss reports.
Rather, “Human Error” is a problem that is systematically connected to people’s tasks, tools, and operating environments and, in conclusion, it is this interplay that we need to understand and work on, in order to not run the risk of Human Error in our systems of work.
If you are interested in learning a little more about how human error studies have developed in recent times, check out this video:
How to fix Human Error?
The change in focus from the individual to the wider operating environment was the birth of what we today call Human Factors. People’s actions are directly influenced by Human Factors, which means that if Human Factors are neglected we actively risk setting people up for failure — With all the associated potential for loss of lives and limbs, material assets, and business opportunities hinging on e.g. CSR and safety performance.
Understanding the work environments onboard ships and how these sometimes makes it difficult for seafarers to live and work on board is key to managing risk in the new safety paradigm — Not theoretically, but in real life as it is experienced by the seafarers. This enables the organization to cater to human needs and support them where needed and wanted. This is not a proposed quick fix like telling someone to just follow a procedure, but it is much more likely to create the fundamental improvements we all want.
Working with such an approach is, however, in practical terms, not part of the maritime industry tradition yet. We are still largely compliance-driven, hoping that legislation and procedures, and telling people to behave, will keep us safe. One could try to raise the argument that we are fine already and there is no need to change, but the insurance industry tells us a different story — that this is just not true, with a cost of losses related to Human Error amounting to 1.6 billion USD over a period of five years and, more importantly, human tragedy!
Since there has neither been a tradition nor tools available for managing Human Factors, it has also been possible to justify not to incorporate Human Factors into the risk management strategy. This is now changing! At Scoutbase we have developed one of the first practical tools aimed specifically at real-time monitoring of Human Factors at sea, and there are other tools and approaches too. OCIMF just published their own Human Factors Approach stating that:
“Mistakes are due to conditions and systems that make work difficult. Understanding the conditions in which mistakes happen helps us prevent or correct them. People know the most about their work and are key to any solution.”
See the entire Approach by clicking below.
And OCIMF is not the only industry body with an increased focus on Human Factors and the role of the seafarers. IMO has formulated a strong vision for their strategic work on Human Factors:
“To significantly enhance maritime safety, security and the quality of the marine environment by addressing human element issues to improve performance.”
Read more about the IMO vision and the highly interesting principles and goals, as they are laid out in Resolution A.947(23) here:
Where does all this leave us?
While it may, at present, still be acceptable (although hardly morally defensible) to neglect to work actively with Human Factors at sea this will not be the case in the near future, as the industry starts to realize that Human Error will remain a costly problem until we start to address this differently and empower those at the frontline.
It is time to realize that knowing the weaknesses in the work systems we operate is a huge strength — because it enables us to act proactively and fundamentally! Before we start taking action we will continue to actively run a big risk, and the likelihood that the next accident will involve Human Error (or should we call it Organizational Error?) is imminent. Lives and assets will be lost because of this, and if we keep blaming the individual seafarers for it we will definitely miss the target.
Should you like to discuss the topics above, feel free to get in touch.
About the author
Mads Ragnvald Nielsen is the CEO at Scoutbase.
Mads holds an MSc. degree in Human Factors & Systems Safety, Master Mariner and marine engineering degrees, and he is an elected Chartered Marine Technologist.
mads@scoutbase.com
