If we want to truly learn from our incidents, Nicole Gray, Principal Human Factors Adviser at the Keil Centre has challenged us to dig deeper. “Human error or non-compliance is not a cause. It is the outcome of a broader system failure. It is the start of your investigation”.
Addressing participants at the DCIIRP event hosted by Senex and Wild Desert on August 7, Nicole Gray explained further. “The human component of our systems is simultaneously the most adaptable and the most vulnerable. When we seek to understand the behaviour from the involved person’s perspective, we can design more error/non-compliance resistant systems”
Nicole’s presentation concluded with the following suggestion for improving how we learn from incidents. Ask: “Why did that action/decision make sense to that (well trained and motivated) person, at that time, with the information that they had?”
Trish Kerin, Director, IChemE Safety Centre then reinforced Nicole’s message by taking participants through a case study activity to examine the causes of ‘human error or non-compliance’ from a simulated real life incident investigation.
Presentations were delivered by: Wild Desert, MPC Kinetic and Easternwell. Case studies were presented about incidents involving: Pinched Finger Injury; Human Behaviour – Breach of Exclusion Zone/Line of Fire; Finger Injury While Rigging Up Bell Nipple.
Josh Doig, COO Wild Desert remarked “It was very valuable to learn more about human factors that can have a negative impact on our workforce which can lead to incidents. Great safety performance requires more than just a great safety management system. It also requires consideration of more personal factors that can influence the attitudes and habits of individual members of the workforce. Wild Desert is proud to share the learning from our incidents with the Safer Together community and provide financial support to this event through sponsorship. I’d also encourage you to host a future event”.
Safer Together Members can access the DCIIRP #14 presentations and summaries of event discussions and feedback here.
For more information about Safer Together click here and the DCIIRP click here.
Contact: [email protected]
*Image: DCIIRP #14, 7 August 2018: Nicole Gray challenges participants to look beyond human error and non-compliance as a cause of incidents