Human error major cause of accidents

A STUDY of the underlying causes of safety incidents in mining has found unintentional human error plays a much bigger role in accidents than is commonly thought. Management system failures or latent errors are at least as significant an issue in generating accidents.

The study was commissioned by the Queensland Resources Council lớn identify the underlying causes of fatalities và significant injury over the past ten years. Over 2000 incidents were analysed to identify six typical, or archetypal, incident types.

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Using a range of human error analysis methods, a đánh giá was conducted of fatality, serious injury and high potential incident data from Queensl&, NSW & Western Australia. The study was conducted by principal retìm kiếm fellows Andrew Morrell và David Cliff of the Minerals Industry Safety and Health Centre (MISHC) at the University of Queenslvà.

The study found that to lớn reduce incidents with a high potential for fatality or serious injury, health & safety management systems needed khổng lồ recognise that humans make errors & that in many cases these are not deliberate.

“Current occupational health and safety management systems, risk assessment processes and Job Safety Analyses generally treat humans as machines, behaving totally predictably, consistently, logically & safely. Human errors may not directly cause accidents or injury, but unless corrected or allowed for, these errors can lead to accident or injury,” the study said.

Archetypal incidents (covering 84% of all incidents analysed) were found khổng lồ be single và multiple vehicle collisions (34%); fall of ground; persons crushed in machinery; persons falling from heights; và persons hit by objects or substances.

Using these archetypes as a base, a further analysis of 109 cases studies was undertaken khổng lồ identify underlying causes for these incidents.

This analysis showed 57% of errors were human mistakes - the person did not have sầu the necessary ability lớn do the correct thing at the time, particularly lớn correct an error of judgement. Cliff said this was contrary lớn popular belief that errors were made deliberately or carelessly.

Slip/lapses - loss of attention that causes a person to do the incorrect thing (slip) or not lớn vày the correct thing (lapse) - accounted for 17% of human errors. Cultural (routine or tolerated) violations, where people choose khổng lồ vày the incorrect thing because they perceive it to be the expected action by their work group and it is tolerated, occurred overall in 20% of cases studied.

Accidents related to ground falls were dominated by cultural violations. Deviant violations, where people deliberately choose to take incorrect actions even though they know it is not tolerated, only account for 6% of human errors.

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For underground coal mines the most significant incident types (in order of importance) are:

· Electrocution – high voltage – trailing cables of shuttle cars etc.

· Single vehicle accidents – due to mechanical failure

· Fire – particularly fires on belts và fixed plant

· Rockfalls/ground control – fall of roof or rib

Though common in coal mines, incidents involving electrocution and fires were not considered in detail because existing controls for these incidents are typically good. Also, low levels of actual injury are associated with these types of accidents.

Overall, the study authors identify three areas requiring major effort from the minerals industry around human error management.

Firstly, operator skills needed to be strengthened to cope with non-normal operations. This might include environmental conditions varying from the “normal”; the change in mining conditions as the mine develops; or approaching loss of control of a hazardous energy.

Secondly, the risk assessment process needed to lớn better identify the need for “Error Forgiveness” in equipment và process operations – that is, equipment should be designed lớn fail khổng lồ a safe state. Protection barriers are needed to lớn defover against human error. The researchers suggest behaviour monitoring will reduce human errors or enable specific defences against the acts.

Thirdly, improving site communications và supervision skills will ensure operators have sầu adequate information on changing conditions to adapt their decision-making.

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While leadership was not studied directly, researchers underlined its importance. Clear communications and guidance on safe working practices is needed, along with, encouragement of workers to report near misses without fear of punishment; encouragement to lớn work safely (versus productively); encouragement of workers khổng lồ actively participate in risk assessments và Job Safety Analyses; và the provision of adequate resources for training.