The evidence is overwhelming. The biggest independent review of the biggest industry in Queensland shows unsafe acts are present and occur just before someone gets hurt.
Routine disruption or inattention is the most frequent unsafe act. This supports the evidence I collected working with more than 25,000 people in the past 12 years.
Organisational factors were either hard to confirm or not present.
What was studied?
In March 2008, Queensland Mines and Energy initiated a review of the role of human factors in mining incidents and accidents in Queensland. What followed was the largest independent study of human factors in Queensland Mining ever.
The study was led by Dr Scott Shappell (if you’re not familiar with his work, take a quick look at this https://www.linkedin.com/in/scott-shappell-8829a22a/). It reviewed 508 accidents/incidents across Queensland in all types of mines between 2004 – 2008 using the Human Factors Analysis and Classification System (HFACS). HFACS is an updated version of Reasons swiss cheese model. Shappell developed it with Wienberg when they worked as investigators for the US Military.
The model is used in multiple industries and on thousands of incidents across the planet. It’s probably the most widely used human factors framework.
What did the study find?
The study showed 94.7% of all incident investigated had one or more causal factors relating to unsafe acts.
Let that sink in for a moment. Almost ninety-five percent!
Of these total unsafe acts, routine disruptions (errors during highly automated tasks which require little conscious effort) were present in 58.9% of events. And decision errors (intentional actions which are inappropriate for the situation) were present in 49.0%.
The remaining unsafe factors, violations and perception errors, were low (4.7% and 4.2% respectively) in comparison.
Perceptual errors were present. The majority of perceptual errors was misjudgment of height, distance, speed and weight. These were linked with physical environment issues like visibility and surface conditions.
Leadership is always a key area for human factors and true to form, they were present in nearly 37% of cases. The greatest leadership factor, by more than double, was inadequate leadership. This factor focused on the leader’s role to provide effective preparedness. A person undertaking a task with a lack of competency was classified as inadequate leadership. Lack of oversight for a task was also classified as inadequate leadership.
Leaderships role in planning were also identified. Classified as inappropriate acts, the study found excessive workloads, unrealistic expectations, failure to provide adequate breaks in only 26% of leadership type factors.
Leadership violations was also low, similar to operator violations. Encouraging to bend rules, violations of SOPs etc. was found in only 3% of cases analysed.
Time of the day seemed relevant. The study found incidents with routine disruption present occurred more on night shift and between 18:00 and 01:59 hours. These time periods align with neurological activity more inclined to go into autopilot, hence resulting in incidents with unplanned events.
In terms of mine types, what was interesting to me is routine disruption errors was constantly the top causal factor and by a long way for underground coal.
The exception was underground metal and non-metal (zine, copper, gold, lead etc.) which has decision errors slightly above routine disruptions. The exception was attributed to these operations having less routine activities and more engaged in deciding how to proceed without SOPs.
From a neurological sense, I can explain the difference as one primarily between conscious decision-making (metal and non-metal underground mines) and unconscious decision-making from the more highly routine underground operation.
Organisational factors were present in only 9.6% of all incidents analysed. This seemed low given the amount of academics presenting paper after paper about organisational influences on the front line.
So what can we do with this knowledge?
Of course, studying the data is interesting but putting knowledge into action is what I’m all about. Here are my top 3 themes of the 10 which I can see and what to do about it:
1. Unsafe acts. 94.7% of all incidents had one or more causal factors present. These are actions taken by operators “in the moment” and are not organization-influenced events.
What to do - Your safety management programs must target improving behaviours as a core component.
2. Routine disruptors of the operator. The study found most of the incidents occur when operators where performing tasks requiring little conscious effort or they were running on autopilot.
What to do - Use neuroscience to understand how we can teach people to pay attention while in autopilot. This skill can be developed and is critical to the success of any safety management program.
3. Leadership. Found wanting in 36.7% of all cases review. The predominant factor was a failure to train, prepare and provide oversight to the teams.
What to do - Focus front line leadership to ensure operator are competent. Leaders learn, then coach and model strategies to deal with routine disruptors (like inattention), with their teams.
Putting these 3 frontline actions into place will significantly move the needle, in the shortest time possible.