Managing Human Error in Incident Investigations for Robust HSE & Process Safety

Process Safety, incidents are often quickly attributed to "human error." While a person's action (or inaction) might be the immediate trigger, stopping the investigation there is a critical misstep. This article explores why focusing solely on human error hinders true learning, how to effectively manage it in incident investigations, and the significant obstacles to implementing a human-centric approach to HSE and Process Safety.

The Problem with "Human Error" as a Root Cause

When an investigation concludes with "human error," it often leads to simplistic solutions like more training, new procedures, or even disciplinary action. This approach overlooks the systemic issues that set people up to fail. As the renowned safety expert Sidney Dekker says, "Human error is not a cause; it is a symptom." It's a symptom of deeper organizational, systemic, and environmental factors that influence human behavior.

Consider these points:

• Humans are not machines: We are not perfectly predictable. Factors like fatigue, stress, inadequate tools, poor design, unclear procedures, and conflicting pressures can all influence our performance.
• Blame culture: Labeling something "human error" often fosters a blame culture, where individuals are afraid to report mistakes or near misses, fearing reprisal. This stifles learning and prevents the organization from identifying underlying vulnerabilities.
• Missed opportunities for systemic improvement: If we simply correct the individual, we fail to address the conditions that could lead to similar "errors" by others in the future. This is particularly dangerous in process safety, where a single human lapse can have catastrophic consequences.

Managing Human Error in Incident Investigations: A Holistic Approach

Effective incident investigation moves beyond the individual and seeks to understand why the error occurred within the broader system. Here's how to manage human error effectively:

1. Shift from "Who" to "Why" and "How": Instead of asking "Who made the mistake?", ask "Why did it make sense for that person to act that way at that time?" and "How did the system allow for this error to occur?"
2. Conduct Comprehensive Root Cause Analysis (RCA): Utilize robust RCA methodologies (e.g., Bowtie, HFACS - Human Factors Analysis and Classification System, ICAM - Incident Cause Analysis Method, 5 Whys, Fault Tree Analysis) to delve deeper into the contributing factors. These methods help uncover:
3. Embrace a Just Culture: Create an environment where employees feel safe to report errors and near misses without fear of unjust punishment. A just culture differentiates between blameworthy conduct (e.g., reckless behavior, deliberate violations) and human error that arises from systemic weaknesses.
4. Focus on Learning, Not Just Fixing: The primary goal of an investigation should be to learn from the incident to prevent recurrence. This involves:
5. Integrate Human Factors Expertise: Involve human factors specialists in investigations. They can provide valuable insights into cognitive biases, human limitations, and the design of user-friendly systems.

Obstacles to Implementing Human-Centric HSE and Process Safety

Despite the clear benefits, several obstacles hinder the adoption of a truly human-centric approach:

1. Deep-Seated Blame Culture: Many organizations have ingrained cultures where finding "culprits" is easier and faster than undertaking a deep dive into systemic issues. This often stems from a lack of understanding or pressure to show immediate accountability.
2. Lack of Leadership Buy-in and Commitment: Implementing a human-centric approach requires a fundamental shift in mindset, starting from the top. If leadership doesn't fully embrace this philosophy and allocate resources, efforts will likely fail.
3. Insufficient Resources and Expertise: Thorough human factors investigations require time, training, and specialized expertise. Many organizations lack the dedicated resources or the in-house knowledge to conduct them effectively.
4. Complexity of Human Behavior: Human behavior is inherently complex and influenced by a myriad of factors. Understanding and analyzing these nuances can be challenging for investigators trained in more traditional, linear cause-and-effect thinking.
5. Pressure for Quick Fixes: In the aftermath of an incident, there's often immense pressure to implement quick solutions to "show action." This can lead to superficial investigations and a reluctance to invest in the more time-consuming, systemic changes required.
6. "Tick-Box" Mentality: Some organizations view HSE and Process Safety as compliance exercises, simply ticking boxes rather than genuinely striving for continuous improvement and a deeper understanding of risks.
7. Siloed Thinking: A lack of collaboration between different departments (e.g., operations, engineering, HR, safety) can prevent a holistic understanding of how various factors contribute to incidents.

Moving Forward: Building Resilient Systems

To overcome these obstacles and truly manage human error in incident investigations, organizations must:

• Educate and train: Invest in training for all levels of the organization, from leadership to frontline workers, on human factors principles and advanced incident investigation techniques.
• Foster a strong safety culture: Promote open communication, psychological safety, and a commitment to learning from mistakes.
• Integrate human factors into design: Proactively design systems, equipment, and procedures with human capabilities and limitations in mind (Human Factors Engineering).
• Empower frontline workers: Involve those closest to the work in identifying hazards and contributing to solutions, as they often have the most valuable insights.
• Measure what matters: Shift from lagging indicators (e.g., number of incidents) to leading indicators that reflect the strength of safety barriers and the effectiveness of human performance programs.

By moving beyond the simplistic label of "human error" and embracing a systemic, human-centric approach to incident investigation, organizations can build more resilient HSE and Process Safety systems, truly learn from their experiences, and ultimately prevent future harm.

Agni Raksha Niti is pioneer in the Accident investigation and root cause analysis. Contact us on agnirakshaniti@gmail.com to develop a skill in your top management on incident investigation and RCA.

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