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Review of Approaches and Theories of Occupational Accidents

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Outline different approaches, recent changes and shifts in accidents investigations, Review definitions and classifications of unsafe acts at workplace, Understand various Theoretical perspectives /assumptions to study causal links between factors and deviations from expected performances. Review on Cognitive and Social theories effecting human capabilities and intention to perform learned task,

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Facts: Occupational Accidents

ILO Global Estimates in 1999, for the year 1998• • • •

264 million non fatal accidents, resulting at least 3 days absence from work Everyday some 970 people die because of occupational accidents 345,500 fatal accidents Accidents, grossly under reported in India, even so 23 injuries per 1000 factory workers were officially reported.

Recent Estimates (ILO & WHO), 2005, for the year 2001• • • •

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Work related accidents and Illness on rise due to rapid Industrialization 268 million non fatal accidents 351,500 fatal accidents Work place accident and illness responsible for the loss of 4% of the world’s GDP in compensation and absence. Accident rates rising in ASIA and LATIN AMERICA In Construction Industry highest number of accidents, about one death in every 10 minutes. Age group- 15 to 24 years and 60 above, prone for accidents

Changes in Accident Causation
(Weigmann and Shappell, 2001)

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Stage 1: Technical Period Stage 2: Human Error Period Stage 3: Socio Technical Period Stage 4: Organizational Culture Period


Approaches to study Human Error

The Person Approach   

Focus on people at sharp end, unsafe acts arise primarily from aberrant mental processes Countermeasures- reduce unwanted variability in human behavior. Limitation: Isolates unsafe acts from system context.

The System Approach 

Focus on upstream systemic factors, Errors are consequences rather than causes, originating from workplace and organizational processes (ex. Poor design, policies and external factors etc), Countermeasures- Change conditions under which human works, build defenses, barriers and safeguards. Limitation; Fails to consider Individual Variability.


Error and Violations: Definition


any member of a set of human actions that exceeds some limit of acceptability (Swain and Guttmann, 1983), any human action or inaction that exceeds the tolerances defined by the system with which the human interacts (Lorenzo, 1990), the failure to achieve an intended outcome beyond the influence of random occurrence (Reason, 1990), a necessary outcome to allow humans to explore and understand systems (Rasmussen, 1990; Reason, 1990) and derivative of operators' social experience of responsibility and values (Taylor, 1987). Rankin (2004) “An error is a human action (behavior) that unintentionally departs from the expected action (behavior)”.


Violations as deviations from operating procedures, recommended practices, rules or standards that are deliberate. Rankin (2004) “A violation is a human action (behavior) that intentionally departs 6 from the expected action (behavior)”.


Errors According to Hinckey(1997)
Example classifications Error of omission, error of commission (selection errors, sequence errors, time errors, and qualitative errors) Inadequate lighting in the work area, inadequate training or skill, Poor verbal communication Errors during the perception stage, errors during the decisionmaking process, errors during the action process Slips in the formation of intention, from faulty activation of schemas, from faulty triggering of active schemas Work load, occupational change, problems of occupational frustration, occupational stress like noise, lighting Design error, operator error, fabrication error, maintenance error Planning, designing and developing, producing, distributing Perceptual processes, mediational processes, communication processes, motor processes Forgetful ness, errors due to misunderstanding, errors in identification, errors made by amateurs

Name or Type Method/ Classification Authors Human Reliability Assessments / HumanSwain Error Probabilities Classifications Performance Shaping Factors (PSF) Ergonomic Method Swain, Meister Alexander

Psychological Classifications Stress Based Classifications Task Based Classification

Norman, Salvendy Altman Dhillon

Classification of Human Performance in Harris and Chaney Industry Behavior Based Classification Mistake-Proofing Classification Berliner Nikkan Kogyo Shimbum



Reason(1990): Behavioral, Contextual and ConceptualSkill Based Errors
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Slips - failures in carrying out the actions of a task Lapses of memory cause to forget to carry out an action.

Mistakes are a more complex type of error of doing the wrong thing believing it to be right.
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Rule-based mistakes - performance based on remembered rules and procedures. Knowledge-based mistakes -operator has to resort to an expert judgment unsupported by rules and procedures.

Violations (Lawton, 1998)•

Erroneous Violations- Unwitting deviations from expected action, Caused by excessive time pressure or work load and inexperience and lack of understanding of rules, not motivated to save time. Exceptional Violations- Extremely risky, occurs when unusual circumstances call for an unusual response requiring knowledge base processing for solution. Situational Violations- Motivated by the desire to keep the job going in adverse conditions, result of factors in employees immediate work environment. Routine Violations- Occur when a shortcut between two points presents itself and is taken on regular basis, usually go unpunished, often have benign effects, promoted by the belief that risk associated with behavior is offset by the skill. 8

Theoretical Perspectives in Human Error Research (Alexandersson,2003)
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Cognitive Perspective Ergonomics and Systems Perspective Medical Perspective Psychosocial perspective Organizational Perspective



Information Processing Models
Rasmussen’s Skill-Rule-Knowledge Framework
1. Skill Based Behavior (SBB)

- smooth, automated and highly integrated, takes place without

conscious control or attention, generally at routine tasks. - Performance is governed by unconscious mental schemas - Errors in connections with lack of attention at tasks. - SBB rely on signals - With deliberate practice and experience, performance becomes automatized - Skill based errors are highest at work.

2. Rule Based Behavior (RBB) - requires conscious effort to recall and follow stored rules. - rely on signs for indication of stimulus
- applicable to tackle familiar problems in which solutions are governed by stored rules - Errors at this level- application of bad rules, misapplication of good rules.

3. Knowledge Based Behavior (KBB)- controlled by highest level of processing hierarchy
- nature of information at this level symbols - stored knowledge helps to execute unfamiliar, complex tasks, requiring -interpretation, diagnosis and some level of decision making for performance. 10


Reason’s General Error Modeling System (GEMS)

The Automatic Subsystem - enormous pool of schemata to activate - no limitation of either number or duration of retention - Two core mechanism in selection of schemata to be activated Pattern Matching & Frequency Gambling - Strong but wrong errors – slips and Lapses (attention problem) -Types of selective attention deficit- divided attention, distraction The Attentional /Controlled Subsystem - powerful logical capabilities - limited, sequential, slow, effortful, and difficult to sustain - rule and knowledge based errors (problem solving failure)

-knowledge based errors- faults in interpretation and causal thinking
or incomplete knowledge.


Norman and Shallice’s attention to action Model
Two challenges for error based theories (Reason, 1990)•

specify control system that allows for the relative autonomy of well established learned programs, Acknowledgment that actions doesn’t always go according to plans

Control Structures
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horizontal- habitual activities vertical threads- higher level attention processes arise from natural tendency to minimize ‘cognitive strain’ and to ‘over utilize’ stored knowledge structures, heuristics, shortcuts that simplify complex informational problems.

Human Fallibility-


SHEL Model

(Hawkins, 1975)


Swiss Cheese Model

Reason (1990, 1993)


Theory of Planned Behavior (Icek Ajzen, 1988)

Attitude toward behavior Subjective norms Perceived Behavior Control



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Process of Accident Causation Common trend of classification of factors (Brown, Wills & Prussia, 2000)
Person as Cause System as Cause System Person Sequence as Cause

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Review of Factors
Person as Cause: Errors as product of wayward
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Mental Processes , Attitude and

Behaviors Accident proneness- few people, unitary trait, general characteristics, as innate and un modifiable characteristics, as explanatory concept Accident Involvement- psychological phenomenon closely associated with accidents, not a stable phenomenon measured through temporary states
                                           Findings Field dependent people were more involved in accidents People with more experience in life events  Type A Behavior, neuroticism, introverts, ambiverts

       Researchers  Goodenough (1976) Kahneman, Ben­Ishai and Lotan (1973) Valerie and Cooper (1991)

Lajunen (2001), Cellar et al(2002) & Clarke and Roberston Agreeableness and Conscientiousness (2005) Cheyne et al(2006) Siu et al (2002) Kolich et al (1999) Brehmer (1994) Elander (1993) Clarke (2006) In ability to sustain attention Accidents rate not related to Age, Occupational Injuries were related to age in curvilinear manner Non work Stressors (Family, financial and social etc) affect individual’s information processing capabilities at work Experience and Deliberate practice sets the task free from conscious processing Hazard Perception Latency Safety Perception, Agreeableness had greater predictive Validity



System As Cause- Errors often depend on latent factors originating mainly form work place design and functions.



Deming (1986), Norman(1988) & Sedwick Errors have roots in their system design (1993), Deming, Latzako and Saunders (1995) Gardner et al(1999) Baberg (2001)

Poor Machine Designs, poor man-machine interface Technology use in system, automation

System-Person Sequence Factors- Errors as product of Organizational, Social, Technical and Operator's evaluation and reaction toward these interacting factors. Safety Culture- IAEA(1986), Attawood et al (2006) Safety Climate- Wallace et al (2006) – management-employee relations and Organizational Support (antecedents of safety climate), Griffin & Neal (2000), Zohar (2002), Cox &Cox (1991) and Barlin et al (2002)

Researchers Chyene, Tomas, Cox and Oliver (1999) Hurst(1998) Findings Employee’s attitude toward management, managers as key group Hardware-people-corporate; people (nature of error) , corporate influence accident process through items- safety culture, training, management processes. Risk perception-psychological strain-risk behavior Organizational preference- safety vs workloads Inaccurate perception or risk, ‘won’t happen to me’ attitude Safety climate, pressure to perform, Perceived risk Optimistic Bias, One’s Self Image, Group Behavior

Rundmo(1996) Haslam et al (2005) Mullen(2004)


Factors related to Types of Unsafe Behavior
       Researchers  Reason(1990)                                            Findings Factors differently associated with categories of unsafe acts,Violations decrease with age, men report more violation, lapses more frequent in women, skill related to violation Violations often immediate predecessor of errors, Safety climate indirectly related to errors

Parker et al (1995), Lawton (1998), Flin et al (2000), Forgarty et al(2001) Rutter et al (1992)

Age, sex, experience vary in prediction of errors and violations, willingness to violate best attitudinal predictor Organizational factor - attitude/motivation, control/ situations, rules/knowledge Safety culture and shared attitudes related to violations Errors – Interacting causes involving physical, Cognitive, Social and Organizational Factors.

Lawton (1998)

Battman and Klumb(1993) Forgarty, Saunder & Collyer (1999, 2001)



Hobbs (2001) Correlation between error-producing factors and unsafe acts

Feyer, Williamson and Cairns (1997) • Skilled Based Errors- Individual work practices, safety equipment and personal
protective equipments • Rule Based Errors- General Equipment Practices • Knowledge Based Errors- management practices