Error Management Quarterly, vol. 1 (1), 2004 Human Factors in Safety Management Systems 1
Copyright Error Management Solutions, LLC 2004
The need to manage human error comes as no great
revelation to anyone involved in system safety. Truth be
told, however, the “battle cry” that human error is
associated with 60% to 80% of all accidents in complex,
high-risk systems has become passé in many organizations.
The reason behind this attitude is that human error statistics
have not changed appreciably in more than a half century!
So, while safety professionals can all agree that something
must be done to reduce errors, a growing number of
executives in the boardroom are becoming skeptical to the
idea that something actually can be done.
Unfortunately, most of us don’t have the luxury of
embracing this liaise faire approach to safety. We are paid to
prevent accidents, or at a minimum, mitigate their
consequences. And although some stakeholders express
cynicism while discussing safety behind closed doors, when
an accident does occur, attitudes quickly change.
Unfortunately, it is at these moments that safety engineers
and managers finds themselves at the center of the storm
answering very pointed questions like, “How could this
have happened,” “Why didn’t you do anything to prevent
it,” and “What are you going to do to prevent this from
happening again?”
As former safety officers and accident investigators
ourselves, we too have felt the painful sting of the boss’
stare when an accident occurs. Perhaps that is why we have
relentlessly pursued better ways to manage human error.
Most safety professionals are very familiar with the
traditional system safety approach illustrated in Figure 1.
While there are many variants to the approach, most
involve the following components: collecting data,
identifying and assessing hazards, identifying/developing
interventions, assessing intervention feasibility, intervention
implementation, and system monitoring/program
evaluation. Ideally, this is a dynamic process involving the
real-time identification of hazards, deployment of
interventions and hopefully, improvements in safety.
Hazard
Identification
Hazard
Assessment
Identify
Interventions
Intervention
Assessment
Intervention
Implementation
Data
Monitor
Figure 1. The Safety Management Process
“Managing human error is fundamental to
maintaining the viability and profitability of
any organization.”
Wiegmann & Shappell
“In high-risk industries, accidents are simply the
cost of doing business.”
Anonymous CEO
“When the only tool you have is a hammer,
every problem becomes a nail.”
Anonymous
HUMAN FACTORS IN SAFETY MANAGEMENT SYSTEMS
Douglas A. Wiegmann, Ph.D. and Scott A. Shappell, Ph.D.
Error Management Solutions, LLC
Error Management Quarterly, vol. 1 (1), 2004 Human Factors in Safety Management Systems 2
Copyright Error Management Solutions, LLC 2004
Historically, this traditional approach to system safety has
been highly successful at addressing mechanical and
engineering problems within a variety of operational
contexts. Albeit, it has been facilitated by the development
of a comprehensive set of engineering tools and techniques
for implementing each step. Not surprising, given the
success of system safety in the engineering world, many
safety professionals have been quick to adopt this same
approach when attempting to manage human error and
other complex human factors issues. But, it hasn’t been
working. Why?
Unfortunately, the requisite tools and techniques for
employing a system safety approach to human error
management have been largely ineffectual or nonexistent.
As a result, it has been virtually impossible to get beyond
the first step in the process - data collection. In fact, when
an accident or incident does happen, the most common
response is simply to collect more data. However, merely
gathering more data about the occurrence of errors is not
the ultimate solution. Organizations have been busy
collecting data for decades. In fact, most safety engineers
and managers are swimming (or perhaps drowning) in data,
particularly given recent advances in technology that have
increased the amount of information available
exponentially.
Most safety professionals have become frustrated with just
watching the human error “data bucket” fill up and are
eager to get beyond this seemingly perpetual data collection
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