Addressing the Hidden Failures in Systems and Behaviours
Authors: Sharp J. , Verhoeve K.N.R. , Groeneweg J. 
Published: December 2007

This paper will discuss the role of human error in accident causation. It will propose a way of rigorously and scientifically identifying the hidden systemic failures as well as identifying how management behaviours and leadership style contribute to accidents.

Human error, which manifests in unsafe behaviours, is an important contributing cause in all accidents. That statement is made in the context that humans create everything in the industrial arena from the design of processes and hardware, to the operating systems and procedures, to the Business and Risk management systems. Consequently the identification of systemic failures and the elimination of human error at all levels of an organisation should be the twin targets of any accident prevention program. Tripod allows an organisation to identify the hidden systemic failures that cause accidents and categorize them in self explaining Basic Risk Factors. Tripod identifies the way in which management decisions can create the conditions likely to encourage unsafe acts in the work place.

Our analyses suggest that, the climate - how people feel about working at a company - can count for 20 to 30% of business performance: getting the best out of people pays off in hard results. If climate drives business results, what drives climate? Research shows that the level of control an organization has over its Basic Risk Factors is related to the climate: the well-being, happiness, health and productivity of employees.

But it is not only hidden systemic failures and management's decisions that contribute to accidents; also management's behaviours and leadership style contribute. Roughly 50 to 70% of how employees perceive their organisation's climate can be traced to one person: the leader.

This paper will describe how to identify hidden systemic failures, as well as it will give a direct experience of how leadership style can affect the business performance in accident prevention or in any other facet of business.

Introduction

Since the publication of Human Error in 19901 a consistent trend in the interest in the contribution of human error to industrial accidents can be noticed. The common factor in this trend is the theory that prevention of human error is most effectively gained by controlling the working environment instead of focusing at the individual who ‘failed’.2,3 Safety does not, as many experts believe, depend on the number of sprinklers and hydrants installed, but a high proportion of accidents and catastrophes are the obvious result of management error.4 According to Rasmussen5 accidents are the result of lack of control: ‘A closer look at major accidents indicates that the observed coincidence of multiple errors cannot be explained by a stochastic coincidence of independent events. Accidents are more likely caused by a systematic migration toward accidents by an organization operating in an aggressive, competitive environment. [..] Safety is a control problem.’

To prevent human error a range of techniques are available, some more effective than others. Initiatives like Unsafe Act Auditing, Qualitative Risk Assessment and Technical Safety Auditing are in many companies applied to increase safety. These techniques may be necessary but are not yet sufficient to further decrease the number of accidents.