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Why do people make mistakes?

Learning Lite

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Everyone makes mistakes….

• Does anyone leave the house thinking… today I will have an accident?

• Does anyone go to work thinking… I hope I slip over today?

• Is there anyone on a worksite thinking… I’ll take a shortcut as I expect that will injure me or someone else?

• Who feels that having an accident is a good thing?

• Have you ever thought, I really enjoy increasing the risk I am exposed to?

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And yet….

• We all make mistakes

• Sometimes we forget to do things

• We think we have to take shortcuts to get a job done

• Sometimes things slip our minds and get missed

• We might have to improvise if it’s a situation we are not familiar with

• It’s human nature… but why do our brains make us do this?

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Are all mistakes the same?

• No! They happen for different reasons

• There is a difference between an Error and a Violation

• Error: An action which was NOT intended

• Violation: Intentionally NOT sticking to rules

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Different type of errors…

Errors have 2 types: Slips & Lapses

• Slips are related to failure in our memory e.g. thinking you mustn’t forget to bring something with you to site - only to arrive at site without it? Ever done that?

• Lapses are related to failure in our attention e.g. you’re listening to a safety brief and you ‘zone out’. This is influenced by alpha state.

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What influences the likelihood of errors occurring?

• There are a number of different factors which can increase errors:

– High or low workload

– Fatigue

– Poor training

– Lack of experience or supervision

– Poor quality work environment

– Individual character traits

– Other things on your mind

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And all these factors…!!INDIVIDUAL REASONSCapacitiesTrainingExperienceSkillsKnowledgePersonalityPhysical fitnessAttitudesMotivation

WORK ENVIRONMENTTemperatureNoiseVibrationLighting

DEMANDS OF THE JOBPhysicalMemoryAttentionVigilance

THINGS IN THE ORGANISATIONManning / rostering Work hours/breaksResource availabilityActions of othersSocial pressuresOrganisational structureTeam set upCommunicationAuthorityResponsibilityGroup practicesRewards and benefits

STRESSESTime pressureWorkloadHigh risk environmentRepetition Fatigue, pain, discomfortConflictDistractionsShift workIncentives

THE JOB OR TASKFrequencyRepetitivenessWorkloadCriticalityContinuityDuration

RULES AND PROCEDURESAccuracyHow clear they areMeaningEase of useApplicabilityAmount of detailHow up to date they are

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So what’s a violation…part 1?

It’s when we know we are breaking a rule but we do it

for a number of reasons…

Routine

• If we have frequently broken the rules, and no-one appears to mind, it becomes a normal way of working.

• Why? It saves time, maybe the rules are too restrictive or there is a lack of rule enforcement, new workers accepting old ways of working e.g. do you ever go over 70 on the motorway?

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So what’s a violation…part 2?Situational

• Where people break the rules on a certain task as a one off because of pressures from the job.

• Why? Due to time pressure, workload, rules are considered to be unsafe in some conditions e.g. Have you ever made a call when you're driving and you don’t have a hands free kit?

Exceptional

• In an emergency a person is forced to violate despite good intention.

• Why? The benefits outweigh perceived risk e.g. do you always return all your tools to the correct place if you need to get home quickly?

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So what’s a violation…part 3?

Optimising

• Working around rules for personal gain.

• Why? Finishing work early, getting home quickly, disregarding rules as not perceived as important e.g. do people always call the Signaller to cross the track on a straight piece of track with good sighting distance?

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That’s all interesting enough but what do we do about it (1)?

Different types of violations require different fixes.

Routine• Remove unnecessary rules, revise

identified rules to make them practical and usable, improve site design to make it easier for people not to take shortcuts or improve reporting of violations to learn why people do it

Situational • Establish positive safety culture

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That’s all interesting enough but what do we do about it (2)?

• Exceptional• Provide awareness of dynamic risk

assessment, support other staff• Optimising• Support staff and raise awareness of

likelihood of optimising violations near ends of shift, increase supervision

• What else do you think you can do?

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So if we all violate what’s the problem?

• Although we all do it sometime in our working lives, there are dangers with violations.

• Will you know what someone is going to do next if you are not all working to the same rules? Be careful about making assumptions

• If rules are routinely violated then it devalues the rules – how do we decide what is unbreakable and what can be flexed?

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How do we make a change?• Reducing errors and violations takes more than disciplinary action…• More effective working comes from:

–Designing sites to be laid out correctly to reduce shortcuts–Changing procedures and rules to be more usable and easy to

apply and stick to–Checking your training to make sure people KNOW what the

rules really are–Improving attitudes towards both work and rules / procedures –Providing supervision where required to stick to the rules

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Reaction… the most important management technique• So, we agree that no-ones goes to work to

have an accident and no-one really wants to injure themselves or their colleagues at work.

–So why, when something goes wrong, someone makes a genuine mistake or violates a rule to get the job done, do you;

• React with anger? • Blame them? • Think they’re idiots?

• Remember, the most important thing to do is make sure they are ok, ask them why they did it, what could be learnt next time?

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So what did we learn? • That people make mistakes• That errors are an unintentional

failure to carry out a task successfully

• That violations are different and that they are an intentional breaking of the rules to get a task done

• The different types of violations occur for different reasons and require different ‘fixes’

• That the most important lesson is to understand why people made an error or made a violation, not to blame them for it