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Reducing Errors and Non-Compliances

We can all make errors and break rules no matter how well trained, experienced and motivated we are to do something right. The challenge is to develop systems to prevent errors and non-compliances initiating an accident. They should be managed proactively as part of the risk assessment.

What makes errors and non-compliances more likely?

Many factors can make errors and non-compliances more likely and these can be categorised as individual, job and organisational factors. The table below shows examples of factors that can increase the likelihood of errors and non-compliances.

Individual Factors Job Factors Organisational Factors Distraction High workload Management prioritising productivity over safety Low skill and competence Poor design of human-machine interface Poor health and safety culture Fatigue Difficulty accessing PPE Lack of communication Ill health Equipment not maintained Inadequate response to previous incidents

Consider the factors, fatigue, human-machine interface design and safety critical communication and how these factors might combine to increase the likelihood of error. For example, consider how the decisions and actions of operators working on a safety critical task in a control room may be influenced by fatigue, poor design and inadequate communication:

  • Fatigue can mean that operators have slower reactions times, are compromised in their perception of risk or lose focus.
  • Poor design of the human-machine interface can mean that operators are working with a display screen with no easy access to critical information (e.g. it is not in their normal field of view).
  • Inadequate safety critical communication can mean that operators have not received critical information at shift handover.

This combination of factors means that such operators are more likely to make errors that can lead to an accident.

How can errors and non-compliances be reduced?

Understanding the different categories of errors and non-compliances that show up in the workplace can help identify ways of reducing them. The tables below show three different categories - skill-based errors, mistakes and non-compliances.

Skill-based errors – slips and lapses

Slips and lapses occur on tasks that are very routine tasks. They happen when we don’t have to think much about the task in order to do it (e.g. driving), sometimes described as being on ‘auto-pilot’. They occur because we get distracted, interrupted or our attention is diverted. One way they can be reduced is with human-centred design e.g. standardising the design of controls.

Types of skill-based error

Examples

Reducing skill-based errors

Slips – a simple frequently performed action goes wrong

Move a switch up rather than down (wrong action on right object)

  • human-centred design
  • checklists and reminders
  • independent cross-check of critical tasks
  • removal of distractions and interruptions
  • sufficient time available to complete task
  • warnings and alarms to help detect errors

Lapses – a short term memory lapse, omit to perform a required action

Forget to indicate at a road junction

Table adapted from the Health and Safety Executive UK

Mistakes

Mistakes are a more complex type of human error where a person does the wrong thing believing it to be right – we make a poor judgement. See the table below for ways to reduce mistakes.

Types of Mistakes

Examples

 

Reducing mistakes

Rule-based mistake – misapply a good rule or apply a bad rule

Misjudge overtaking manoeuvre in unfamiliar, under-powered car

  • plan for all relevant ‘what ifs’ (procedures for upset abnormal and emergency scenarios)
  • regular drills/exercises for upsets/emergencies
  • diagnostic tools and decision-making aids (flowcharts; schematics; job-aids etc.)
  • competence (knowledge and understanding of system; training in decision-making techniques)
  • organisational learning (capture and share experience of unusual events)

Knowledge-based mistake – novel situation where there are no rules but insufficient knowledge

Misdiagnose a process upset due to lack of experience and knowledge

Table adapted from the Health and Safety Executive UK

Non-compliances

Non-compliances are very common in our work and our everyday lives. There is a tendency to think that non-compliances are what ‘other people’ do. Non-compliances are deliberate deviations from rules, procedures, instructions and regulations and are mostly motivated by a desire to complete the task.

Types of Non-Compliances

Examples

Reducing Non-Compliances

Routine – breaking a rule has become a normal way of working

Driving beyond the speed limit

  • improve risk perception; promote understanding and raise awareness of ‘whys’ and consequences (e.g. warnings embedded within procedures)
  • increase supervision
  • eliminate reasons to cut corners (poor job design; unnecessary rules; unrealistic workload and targets; unrealistic procedures; adverse environmental factors)
  • improve safety culture (e.g. active workforce involvement)

Situational – breaking a rule due to job pressures

Not wearing PPE because it’s uncomfortable in ‘this situation’

Exceptional – happen in emergency situations where there is a belief that breaking rule is more beneficial

Captain Sully landing a plane in the Hudson river

Table adapted from the Health and Safety Executive UK

In some cases it can be difficult to place an error or non-compliance in a single category. There may be a combination of underlying causes requiring a combination of preventative measures.