Understanding the root causes of incidents is essential for every organization aiming for high safety standards and operational excellence. While equipment failures and process issues are often the focus of investigations, a significant portion of workplace incidents arise from human error. Conducting a thorough human error analysis not only helps in uncovering the underlying factors leading to mistakes but also plays a critical role in preventing future occurrences. By unraveling the true reasons behind errors, organizations can develop robust controls, enhance safety culture, and achieve lasting improvements. But how exactly should human error analysis be approached following an incident?
What Is Human Error Analysis?
Human error analysis is a systematic method used to identify, understand, and address the factors that contribute to unsafe actions or decisions by individuals in the workplace. Unlike simple blame assignment, this process delves deeper, seeking out the environmental, organizational, and psychological causes of an error. The goal of human error analysis is not to punish the individual but to reveal the conditions or system failures that set the stage for their mistake. By targeting these root causes, organizations can create safer processes, clearer procedures, and more reliable training programs.
Preparing for Human Error Analysis
Before conducting a human error analysis, it’s important to gather all relevant information about the incident. This includes incident reports, witness statements, operational data, and any available CCTV or electronic logs. Assembling a multidisciplinary investigation team with representatives from health and safety, operations, and human resources ensures different perspectives are considered. Confidentiality should be assured to encourage honest input, and the process must remain objective and free from assumptions of guilt.
Key Concepts of Human Error
Not all errors are the same. Understanding the different types helps in selecting the right analysis approach. Human errors are generally classified into slips, lapses, and mistakes.
Slips are errors in execution—accidental actions, such as pressing the wrong button or misreading a display, despite knowing the correct action.
Lapses refer to memory failures, like forgetting to complete a checklist step due to distractions or interruptions.
Mistakes occur when someone makes a poor decision or chooses the wrong action, often as a result of insufficient training, unclear procedures, or misjudgment.
By identifying which type of error occurred, investigators can look beyond individual behavior and explore deeper contributing factors.
The Process of Human Error Analysis
Conducting a human error analysis involves several critical steps. Each step builds a foundation for a thorough understanding of how and why the error occurred.
Data Collection and Timeline Reconstruction
Start by establishing a clear sequence of events. Interview everyone who was involved or observed the incident; their perspectives might reveal discrepancies between what processes require and what people actually do. Review equipment data, logbooks, work permits, and training records. This helps reconstruct the environment in which the error took place and uncovers factors like time pressure, fatigue, or confusing instructions.
Identifying Error Triggers
Next, determine what triggered the error. Was the person interrupted, overconfident, or working in an environment with excessive noise or distractions? Sometimes, a complex or poorly designed task can set someone up for failure, even if they are competent. For example, if an operator bypasses a safety control to complete a task quickly, is it a case of individual negligence, or does the system incentivize speed over safety?
Applying Human Factors and Error Models
Various models help investigators analyze errors systematically. The Swiss Cheese Model, developed by James Reason, is widely used in safety analyses. This model visualizes defenses as layers of cheese with holes—weaknesses or gaps. Incidents occur when the holes align, letting an error pass through all defenses. By examining organizational policies, supervision, equipment design, and working conditions, teams can identify which “holes” contributed to the incident.
Another tool, the Human Factors Analysis and Classification System (HFACS), provides a structured way to categorize errors and their causes. HFACS looks at unsafe acts, supervisory influences, preconditions for actions (such as mental state, physical environment), and organizational factors. Using such models expands the investigation’s focus from the individual to the entire system.
Looking for Systemic Issues
Effective human error analysis always goes beyond the immediate actions of those involved. Investigators should ask why those actions made sense at the time. Were procedures confusing or difficult to follow? Was the workload too high? Did supervisors provide adequate oversight? For instance, if multiple employees perform a task incorrectly, it’s likely a system or design issue rather than individualized incompetence.
Developing Recommendations and Controls
The final step is to translate findings into meaningful improvements. Recommendations should address both immediate and underlying causes. Updating procedures, enhancing employee training, redesigning job aids, or improving supervision are common solutions. Where feasible, apply engineering controls to reduce human reliance, such as interlocks or automation that prevent incorrect actions.
Crucially, recommendations must be realistic and sustainable. For example, expecting workers to simply “be more careful” is ineffective; robust controls change the environment or process to make errors less likely or less consequential.
Practical Example: A Real-World Scenario
Consider a scenario where a technician accidentally shuts down the wrong pump in a processing facility, leading to product loss. The initial assumption might be a lack of attention. A closer look, however, reveals multiple contributing factors. The pumps were poorly labeled, procedures had confusing diagrams, and the technician was covering extra shifts due to staff shortages—leading to fatigue.
A human error analysis uncovers these underlying issues: suboptimal labeling (system design), poor documentation (procedure), and excessive workload (organizational). The company responds by improving labeling standards, clarifying procedures with updated visuals, and adjusting staffing to manage fatigue. As a result, similar incidents are prevented, and the work environment is safer.
Ensuring Continuous Improvement
Human error analysis should not be a one-time activity but part of a continuous improvement loop. Lessons learned from incidents must be shared across the organization, and corrective actions should be tracked for effectiveness. Regularly reviewing procedures, employee feedback, and near-miss reports helps spot potential for error before it results in harm.
The Role of Leadership and Safety Culture
A successful human error analysis requires organizational buy-in. Leadership sets the tone by supporting a “just culture,” where employees feel safe to report mistakes without fear of blame. This transparency is crucial for gathering honest information and making sustainable changes. Investing in ongoing human factors training for investigators and frontline staff also builds capacity for high-quality analyses.
Summary
Human error remains one of the most significant contributors to workplace incidents, but it is rarely the result of carelessness alone. Conducting a human error analysis allows organizations to look beyond surface-level causes and address the system-level factors that shape human decisions and behavior. By approaching incidents with a structured, non-blaming attitude, companies can develop targeted, sustainable corrective actions that enhance overall safety and efficiency. In the end, understanding—and learning from—human error drives the journey toward a safer, more resilient workplace.