Bolt-on human factors?
Can the human factor be “bolted on” to your risk management system?
Ride designers, manufacturers, owners and maintenance staff have now pretty much got modern machines to a condition where they rarely fail in ways that cause serious accidents or incidents. In most cases where the risk to them is greatest, passengers are now contained so they cannot get into trouble and most pedestrians etc. in the parks are kept out of danger with perimeter fencing.
The greatest risk from rides now comes from the people who operate and maintain them on a daily basis and this situation has long been acknowledge by other high hazard industries.
Mention Human Factors (HF) to most people and they automatically think of ergonomics and the reduction of hazards associated with posture, twisting etc.
There is a tendency to “do human factors” or not change current risk management practice other than “bolt-on” a “human factors” element. The human factor is more, much more!
The airline industry has its Dirty Dozen; twelve of the most common human error preconditions, or conditions that can act as precursors, to accidents or incidents. These are:
- 1. Lack of communication
- 2. Distraction
- 3. Lack of resource
- 4. Stress
- 5. Complacency
- 6. Lack of teamwork
- 7. Pressure
- 8. Lack of awareness
- 9. Lack of knowledge
- 10. Fatigue
- 11. Lack of assertiveness
- 12. Norms (i.e. the way we do things)
How many of those do you (or would your staff) recognise? How many times every day are your operators diverted or distracted by cumbersome procedures or unnecessary warning and alarms, poorly designed work stations, pressure to get the queues moving or simply being bored?
Have you considered what could be done to improve their situation, make them more reliable and more likely to do the right, rather than the wrong thing in any given circumstance?
The HSE produced guidance HSG48 (Reducing error and influencing behaviour) states,
“Human factors refer to environmental, organisational and job factors, and human and individual characteristics which influence behaviour at work in a way which can affect health and safety”.
HF can be broken down into 3 categories:
Job factors including:
- illogical design of equipment and instruments,
- constant disturbances and interruptions,
- missing or unclear instructions,
- poorly maintained equipment,
- high workload,
- noisy and unpleasant working conditions.
Individual factors including:
- low skill and competence levels,
- tired staff,
- bored or disheartened staff,
- individual medical problems.
Organisational factors including:
- poor work planning, leading to high work pressure,
- lack of safety systems and barriers,
- inadequate responses to previous incidents,
- management based on one-way communications,
- deficient co-ordination and responsibilities,
- poor management of health and safety,
- poor health and safety culture.
Slips, lapses, mistakes and violations
The HSE state that, through significant research, there are four fundamental types of human failure:
- Slip: A simple frequently performed physical action goes wrong.
- Lapse: A lapse of attention or memory.
- Mistake: Not understanding properly how something works or an error of diagnosis or planning.
- Violation: A deliberate breach of rules and procedures.
HF in the design of machinery
For the benefit of this paper, and leaving aside the Machinery Directive, let us call a theme park ride a “machine”.
When designing a machine, we use the standard ISO 12100 (Safety of machinery – General principles for design – Risk assessment and risk reduction) to ensure that all specific risks have been identified and reduced, where practical. Embedded into ISO 12100 is the human factor, throughout the whole life cycle of the machine. The standard states that machines should be assessed for reasonably foreseeable misuse and defines this as,
“…use of a machine in a way not intended by the designer, but which can result from readily predictable human behaviour”.
Examples of reasonably foreseeable misuse include:
- loss of control of the machine by the operator (especially for hand-held or mobile machines),
- reflex behaviour of a person in case of malfunction, incident or failure during the use of the machine,
- behaviour resulting from lack of concentration or carelessness,
- behaviour resulting from taking the “line of least resistance” in carrying out a task,
- behaviour resulting from pressures to keep the machine running in all circumstances, and
- behaviour of certain persons (for example, children, disabled persons).
ISO 12100 says that HF shall be taken into account in the risk estimation, including, for example,
- the interaction of person(s) with the machinery, including correction of malfunction,
- interaction between persons,
- stress-related aspects,
- ergonomic aspects,
- the capacity of persons to be aware of risks in a given situation depending on their training, experience and ability,
- fatigue aspects, and
- aspects of limited abilities (due to disability, age, etc.).
Again, how many of your rides do you believe were designed and manufactured with these factors in mind? How many do you think were designed to present the operator with all the information they need (and no more), at the right time, in the right form so they can make the right decisions?
How many were designed with little regard for the operator so they have to make time consuming and awkward compromises to do what they should and get what they need with the consequent risk they won’t do it?
How can Finch help?
The tightening of the regulatory framework and both the regulator and public’s expectation that all risks are managed effectively and appropriately mean that human management systems must not be left behind as technology changes.
Finch maintains a clear forward look in this industry and can help you to build, develop, audit, and maintain systems and processes that will allow you to comply with your legal and corporate duties as well as the public expectations placed upon you.
We are unique in our ability to offer a seamless consulting, expert witness, legal and learning services to support you, who work and train together to understand your industry and your risks. Our expertise encompasses:
- Mechanical, electrical and civil engineering and occupational health and safety expertise to assist in understanding what could go wrong, what can be done to make equipment safer and ensuring that the appropriate operation and maintenance documentation is in place and is good quality;
- Machinery and functional safety specialists that can assist you in evaluating and designing out risks.
- Experienced practical lawyers specialised in health and safety who can give context to risk management and advise, defend and represent clients under investigation.
- Human factors and behavioural experts who can help you to manage and achieve safer behaviours to minimise risks;
The human factor cannot be “bolted on” to your risk management system, like an optional extra or attachment to your machine or ride. It is more fundamental than that: the human factor must be integral and embedded into every risk management decision you make.
If you want to understand how the human factor can become integral to your attraction risk management processes, please talk with Finch for more guidance.