Workplace Safety Violations

I have read several posts regarding incident investigations relating to human error as a factor. I really believe this is an area of poor understanding for many. I read an interesting article recently outlining the fact that in many cases the main corrective action (for many incidents not just human error) is re-training.

I do appreciate that a blame culture in any work place is never going to lead to a fully successful operation or business. I do see however, a common tendency to look for systemic incident causes rather than the human factor. I see a confusion between blame and accountability with re-training being used as a compromise for managers / supervisors and HSE advisors who are sadly inept in concluding their investigation findings. We must remain impartial, analyze the facts and deliver the real causes with effective corrective actions.

My recommendation to all is to study human error in order to fully understand where a lot of HSE professionals and organizations are erring. Then you must analyze investigation report and not try NOT to fit the "incident' in to a specific category. Let the facts guide you! You must also note that incidents may have several causative factors and root causes and not look for one single event.

Human error can simply be broken down in to mistakes and violations. So what is a violation? A violation is a deliberate and intentional deviation from the rules procedures, instructions or regulations. These acts are rarely acts of vandalism or sabotage but are often carried out to get the job done. A violation can be broken in to 3 sub classifications: Routine, situational and exceptional.

A Routine Violation - A regular or continual deviation, to the point where it is the normal way of working.

A Situational Violation -- Rules are broken due to pressures of the job. These can be due to things such as time pressures, staff shortages, lack of equipment etc.

An Exceptional Violation - Quite rare and infrequent. These tend to only happen when things go wrong. A risk may be taken to solve an urgent problem. The violation is understood, but it is the "least worst" choice.

As you can see there should be no reason to train or re-train anyone committing violations. The misconception that you should discipline for violations scare a lot of investigators away from this finding.

Would you discipline a worker who violates your procedures because he/she is under pressure to get the work done and you are short staffed? Would you discipline a worker involved in an event where you find that is the way everyone does a task and the Supervisors and/or Managers are aware? It is very easy to think of many other examples. The real violation may well lie with the supervisor or manager?

We must also recognize that we can get workers who are trained, competent and fully resourced that make their own decision on their way of completing a task. In these cases discipline may well be the answer. Again, in these situations why re-train? A good investigation will lead you to the whys and give ideas of actions to prevent.

I know that some of the issues above are 'sensitive' and you may well receive push back at all levels. Times are hard and organizations are not looking at outlay of $. Unless addressed however the incidents will continue and the direct and indirect cost associated will mount.