Mistakes are not inevitable and near misses can be avoided. Improving the culture of businesses and teams is fundamental to effective health and safety management. So, what is a mistake and how might this lead to a near miss?
I will review how we might better understand and deal with mistakes at work by looking a the psychological research behind it. This information can help you to reconsider how you approach incidents at work and reduce the likelihood of near misses.
A climate survey tool is a great start to find out what people really think about how health and safety is managed in the workplace. (Climate survey tools can be found on the HSE website). We will then look at learning through mistakes and near misses.
Different kinds of mistakes
The HSE publication HSG 48 -“Reducing error and influencing behaviour” provides a useful definition of mistakes as a “complex type of human error where we do the wrong thing believing it to be right”. These types of errors involve a failure to mentally process information correctly; this inevitably leads to mistakes being made. This is different from deliberate “rule violations”.
There are two quite different types of mistakes: “rule-based” and “knowledge-based”. An explanation of each type follows:
They happen because people have a strong tendency to follow familiar rules or adopt previously used solutions. Behaviour is based on remembered rules. So if the remembered rules or solutions are inappropriate for the current situation, mistakes will be made.
They tend to happen in unfamiliar situations where people need to decide on a particular course of action by thinking from first principles or by using analogies to solve problems. However if their knowledge is incorrect, their reasoning can lead to mistakes being made. These types of mistakes are referred to as miscalculations or misdiagnoses.
What is important to note is that these kinds of mistakes typically occur with people who are both experienced and trained. In both types of mistakes: rule-based and knowledge-based, the person responsible believes that they have done the right thing. These approaches increase the practical difficulty of identifying any mistakes made, who the person responsible is and the potential cause. Who would own up to a mistake at work if they thought it might lead to an unpleasant outcome? In such situations, the influence of the health and safety culture on behaviour becomes very clear.
How do we reduce mistakes occurring?
A clear solution involves managers designing out the need for complex decision-making in safety critical tasks. People need clear procedures and instructions that are known and accepted by everyone using them .
When hazards are identified during risk assessments for example, and incidents, near misses are investigated, the potential causes of mistakes should also become clear.
Role of managers when reviewing why mistakes occur
Supervisors and managers have a very important decision-making role in both risk assessments and incident investigations. If they do not fully understand the impact of their decisions, it can promote a negative health and safety culture.
A typical scenario is: if a manager is investigating an incident and adopts a rule-based approach, he/she assumes that a worker has been trained so they must have been competent to do the job, the manager could then assume that they know the cause of the incident. The manager will simply blame the worker without considering other possible reasons for any mistakes that were made. This is called causal reasoning.
So what is the psychology behind making mistakes?
There has been much psychological research about features influencing mistakes occurring. Here are some of the psychological terms used: a cognitive bias – the tendency to attribute blame to a person without asking a few more questions about how and why a mistake occurred. A cognitive bias is a systematic error in thinking which affects our decision-making. So a cognitive bias may affect how we look at a person’s character to explain their behaviour rather than taking stock of the features of the current situation. This behaviour will lead to a “fundamental attribution error”.
How to change how we typically deal with mistakes at work
One way of trying to avoid this typical human behaviour is to think of all the possible events that could have caused you to behave in the same way. This should enable you to realise that people do not always “act as they usually would” in all situations.
How incorrect judgements can be made
Another way of thinking that may lead to incorrect judgements or knowledge-based mistakes is a “confirmation bias”. This describes the tendency to search for and interpret “facts” in a way that affirms existing beliefs.
An example of another bias leading to incorrect judgements is an “overconfidence effect”. This describes the difference in what people actually know and what they think they know.
Biases such as these two examples can be avoided by challenging our own thoughts and considering how the information given to the workforce is understood.
Review how you deal with mistakes and near misses
So, although it’s a complex picture, we can do a lot to reduce the chance of people making mistakes in their jobs. This process should be used when conducting risk assessments, developing safe systems of work and carrying out incident investigations. Asking simple questions such as “is the rule appropriate and fully understood?” will help to identify how and where mistakes might be made.
So, if we want to improve our health and safety culture, we must deal with our mistakes and near misses effectively and communicate clearly. A positive and open health and safety culture that welcomes the reporting of near misses will enable us all to learn from our mistakes.
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