Human Factors – Change the person or the context? Procedures that we don’t always follow, even if we should. After incidents and near misses in the outdoors much of the conversation around learning from these events is focused on the performance of the instructor or guide concerned.
I recognise that as normal, in that the instructor or guide is often closest to the incident and may even consider themselves directly responsible as an autonomous practitioner.
Having delivered a few human factors and decision making workshops for the Association of Mountaineering Instructors (AMI), many of those present have shared stories, some from different environments. Thanks to Stephen McCall from Scottish Rock and Water for sharing this tale of a near miss in a previous job as an apprentice commercial mechanic.
10 seconds later, I was chalk white, couldn’t stand up and truly realised that I had just nearly been cut in half!
Limitations of Human Performance
For many of us the term Human Factors is synonymous with the limitations of our own performance. While it is logical to consider the events closest to the incident, such as decision making and other Non-technical Skills like Situational Awareness, it is important to take a broader view. Doing so allows us to understand the context of the work and the incident, the external factors that contributed and why it made sense to the instructor or guide at the time.
Conclusions of incident reports sometimes go further to make recommendations of different types which simplify the cause. For example, not paying attention when tying in or clipping in cows-tails etc.
Sometimes we try and change the person by providing additional training, providing additional monitoring or in rare cases remove them from the activity…
But what about the context? In the above example a mistake tying into a rope could be due to time pressure from a short session, poorly thought out operational procedures, distraction or “brown standard” ratios. These issues need to be considered from a different perspective to see the full picture. It is often these other external factors that shape performance and also allow errors to flourish. Keep an eye out for another blog in the pipeline that lifts the bonnet on safety management systems.
Stephen has shared his experience here, and it appears unedited… He talks about his own limitations and Non-technical Skills, but it is worth zooming out to see the wider context of work, procedures and culture.
“Before becoming a Mountaineering Instructor I had a near miss when I was a commercial mechanic. I thought you would probably find it interesting due to the lack of decision making, situational awareness along with other influences that led to the incident.”
“I specialised in refuge and recycling trucks in the later parts of my career, mainly hydraulics and electronics. Normally the drivers would bring the trucks into the garage with any faults at the end of their shift. On this particular refuge truck one of the rear hydraulics rams was causing a problem, the one that controls the “packer” (basically the part you can hear compressing the rubbish together, after the bins have been tipped in the back).
“To remove the ram, you would want the oil to be in the closed position, so you would work the hydraulics until this was achieved then start the work of removing the ram. It was “standard” by the people who I looked up to, and I had been shown to put a very heavy duty axle stand under the packer blade. I had carried out this procedure many times before and this was seen to be normal.”
“When removing the pins that hold the ram in position, one of them dropped and slipped under the axe stand. Not thinking anything of it, I removed the ram and remaining components out of the back of the tailgate area. I went back to get the remaining pin that had slid under the stand. To get to the pin I hung over the area that the bins tip in (kind of like what the bin would look like, with my feet hanging out the back but my top half under the blade). The pin was a little stuck under the stand, I pulled a bit harder, the stand slipped out and the blade came crashing down as I was exiting the rear. It was such a crash when it hit the bottom that the whole 35 ton truck was bouncing up and down on the suspension. I thought to myself “bloody hell that was close” and started to walk away. 10 seconds later, I was chalk white, couldn’t stand up and truly realised that I had just nearly been cut in half!”
On reflection, probably more so now that I have had training and experience in risk management and prevention it has provided me with clarity of how many areas that were lacking for this to have been as close as it was. I’m sure you’ll have many more to add but I have come to these conclusions:
1. There was a lack of formal training in this area and this had been filtered down through the team to apprenticeship level, lack of communication, both in the workshop and from management, maybe this had changed over the years but it had become standard practice.
2. I was trying to be accepted in the garage and try to achieve speedy times for jobs, at times making shortcuts in safety to get a quicker outcome.
3. I looked up to the people who were training me and fell into the expert halo. It must be fine if the experienced guys were doing this?
4. I had no idea of just how quick something would happen if the stand came out, which I consider now to be a lack of situation awareness.
5. When trying to remove the pin, although I can’t remember 100%, I was obviously missing the fact that I had around 1 ton of metal with a sharp edge hanging above me while I was trying to pull out a pin that was stuck under the stand! Again, lack of situational awareness.
6. After the event, I blamed myself that I hadn’t put the stand in properly and was too embarrassed to think it was anything or anybody else’s fault. It hadn’t happened to anyone else, so ‘”it must have been something I did wrong”. I felt that I was at the bottom of the pack in terms of the team, so I was too scared to put my hand up to say that I had made a mistake but also that the safety procedure wasn’t safe.
7. Through the whole incident I was probably thinking of anything but the situation I was currently in i.e. how quick can I complete this job, will I get good feedback? What is the next job? This was due to the fact that the job itself was quite straightforward, remove 2 pipes, 2 pins and take the ram out so it didn’t need much technical thinking. But with reduced situational awareness and complacency it showed to be the closest I have ever come to feeling like I was over ‘the line’ but sneaked back at the last second…
I have never thought about this in so much depth, your course and delivery got me thinking about it at a different angle and has actually helped me process the model with a real event.
I hope this is of interest and it maybe shows it from a real event in a different industry, especially from an apprentice’s view.
Why don’t we don’t always follow procedures?
In this case it sounds like a Stephen wasn’t trained in a definitive procedure (even if it existed). It was a case of just getting the job done with little guidance from more experienced mechanics. There are clearly issues around communication and the culture of the work environment.
Procedures are not used because:
- Accuracy – procedures are inaccurate or out of date
- Practicality – they are unworkable, make work more difficult or restrictive, or are time consuming
- Optimisation – people normally find a better work around, or the procedure doesn’t describe the best way of doing the job
- Presentation – not sure which is the right procedure, they are complex, or the information needed cannot be found
- Accessibility – they are difficult to locate, or people are not aware that procedure exists for the job they are doing
- Policy – people do not understand why they are necessary, or there is no policy on when they should be used
- Usage – experienced people think they don’t need them, they resent being told how to do their job, they rely on memory, or assume they know the procedure.
My conclusion wouldn’t be as harsh as Stephen has been in his own reflection of events. Not only does this demonstrate that procedures are important, but they need to be designed carefully. If you are in the position of having to renew or write standard operational procedures in the outdoor sector, then speaking to those working on the ground is a good place to start.
If you liked this article you may wish to read The Normalisation of Deviance and how I nearly killed myself at an avalanche “safe” venue… Check out Assured Training or Assured Expertise.