Preventing Accidents at Work

Background

In 2004/5, 220 people were killed and over 150,000 injured at work in the UK. Two of The Keil Centre’s clients, BP and Balfour Beatty Rail, wished to deepen their understanding of the human and organisational factors which influence accidents in the workplace. Whilst safety levels in these hazardous industries are already high, the clients wanted to focus on identifying improvements which could contribute to eliminating all incidents. They had found that their existing, conventional means of incident analysis did not yield a good understanding of why people had behaved unsafely, or provide strong recommendations to influence future behaviour.

Practical methods had to be developed, and taught to very experienced senior health and safety specialists, in a way that engaged and enthused them, without devaluing their existing expertise. As the methods would have to stand up to legal scrutiny, they had to be strongly evidence-based, both in terms of the underlying theory, and the use of evidence to reach conclusions about human behaviour.

Working alongside internal company health and safety specialists, The Keil Centre developed a practical set of human factors analysis tools (HFAT) which encompassed violations, errors and aspects of safety culture.

What was Involved

The first author completed the organization’s incident investigation training course, to become familiar with the existing methods and process. When analysing unsafe behaviour, an important distinction is made in the human factors literature between behaviours which are intentional (often termed a violation) and unintentional (often termed an error) (Health and Safety Executive, 1999). It was noted that the existing root cause analysis method in use included consideration of violations, but did not directly address human error. A sample of completed incident investigations were analysed using a human error analysis technique, the results of which suggested that explicit inclusion of human error in the root cause model would allow this aspect of human performance to be systematically considered.

In this organization, a very large number of people had already been trained in the use of the existing incident investigation process, and were familiar with its use. It was therefore deemed most practical to introduce structured methods to help investigators, who did not possess specialist human factors expertise, to ‘step-out’ of the existing process, where they wished to analyse why people behaved as they did, and formulate appropriate recommendations to influence future behaviour. The following principles were applied to the design of the analysis toolkit:

• tools to be based on sound analytical methods, supported by existing research;
• methods designed to help the investigator reach their conclusions on the basis of evidence gathered;
• methods to be suitable for use by trained investigators, who are not human factors specialists;
• toolkit capable of being imparted via a 2-day training course, delivered by internal company personnel;
• toolkit to permits analysis of intentional and unintentional unsafe behaviour and identification of trends suggestive of a problem with certain aspects of safety culture;
• provide written support, guidance and examples for investigators.

A four-step process was developed, supported by structured worksheets, which allowed investigators to:

(1) Accurately define and describe the behaviour(s) they wished to analyse.

(2) Determine, on the basis of the evidence available, whether it appeared the behaviour(s) were intentional or unintentional.

(3) For intentional behaviour, apply ABC analysis.

(4) For unintentional behaviour, apply human error analysis.

Prior to finalization of the tool-set, and the widespread implementation of training in their use, a peer review was held. This involved scrutiny by internal company HSE professionals, and a range of external human factors experts from the process industry, regulatory, academic and aviation domains. The proposals, methods and draft toolset were supported, and some minor suggestions for improvement implemented. Implementation in the first client organization involved a train-the-trainer model. The authors ran a 2-day pilot course for 20 delegates, which included four internal company staff who subsequently trained approximately 100 of their most-experienced incident investigators worldwide. The next stage of implementation involves training a larger number of less experienced incident investigators. The 2-day course involved minimal theoretical input, with the majority of time being spent working in small groups to apply the methods to a range of real incidents, identify and analyse errors and violations, and formulate recommendations which were compared to a set of model answers.

Subsequently a similar approach has been taken with three other organizations in rail maintenance and contracting, and offshore engineering. With these organizations, it was necessary to develop some industry-specific case studies and examples for the course delegates to work upon.

Outcomes

Over 100 of the clients’ most experienced incident investigators received HFAT training. The HFAT course was evaluated immediately after its conclusion, and was very well-received.

In addition, the initial objectives for the HFAT project were to provide practical tools which non-psychologists could use independently, to add value to their investigations. To evaluate the practical impact and benefits of HFAT, all HFAT delegates were contacted 12 months after course completion. The results of this evaluation were very positive:-

• HFAT tools had been successfully used in over 100 fatalities and other serious incident investigations
• 96% of users had found the HFAT tools useful
• HFAT had significantly enhanced their understanding of human behaviour, and added "science" to what had been "gut feel"
• HFAT had led to better recommendations to influence behaviour, and prevent a recurrence.
• HFAT had a "good, structured approach " and "expanded the investigators’ scope of what they need to dig at to understand behaviour, and get to the underlying causes"

Graham Reeves, Human Factors Advisor at BP, said, "The Keil Centre was very responsive to client demands, and the practical solutions arrived at would not have been possible without close collaboration between the Keil Centre and BP."

Plans are now being progressed to extend the use of the HFAT tools to a much larger population of less-experienced investigators, who deal with many more less serious incidents.

Following the lead of the first two clients, the HFAT methods have also been implemented in steel-making, chemical manufacture and logistics. The UK Health and Safety Executive also plans to train some offshore safety inspectors in their usage.

Practitioner of the Year Award 2006

In 2006, Ronny Lardner & Richard Scaife, who developed the HFAT project, scooped top prize in the first-ever award for The Occupational Psychology Practitioner of the Year, held by the Division of Occupational Psychology.

Presenting the award, Deutsche Bank Head of Learning & Development, Noel Hadden, said: "Occupational psychologists make a real and positive difference to the way our organisations operate. These awards make me optimistic about the direction in which the discipline is going and the quality of work and research that occupational psychologists are delivering."

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