ABC news reported today “Leading Seaman Michael Bass, 22, was seriously injured while on patrol last year on Thursday Island, off far north Queensland, but was kept on the island for three days without follow-up medical attention.”
The family of Leading Seaman Bass reported that a Navy review confirmed appropriate procedures were in place but human error resulted in Leading Seaman Bass waiting 3 days for medical treatment.
Human error occurs as a factor in many major incidents, maybe not the major root cause but often a significant contributing factor. Human error is not code for blaming someone, in the Navy, and in all other enterprises individual workers are balancing many pressures at any one time, they work in complex environments with many competing demands.
No one in this situation has a pocket manual that they whip out every 5 mins that tells them what to do next; they need to make decisions that weigh up the pressures and competing demands they have on them.
When a significant near-miss occurs, Leading Seaman Bass is reported to have been “near death” by the time he received treatment in Darwin Hospital, the opportunity to objectively analyse the competing demands on individuals can lead to real systemic change.
We use the RAID™ human factor analysis model. With the RAID™ model unwanted human behaviour is a consequence of one of three factors:
- Individual purposeful decision not to observe the requirements.
(intentional error)
- Individual physical or mental mistake. (mistake)
- Individual response to an obstacle in appropriate behaviour.
(progress blocked)
The first option is rarely the reality for day-to-day operations and often provides limited opportunity to develop a systemic response – the other two options are more common; a person just slips and hits the wrong button or attempts to follow procedure but one or more of the resources for the next step is not available; so they are required to rely on their individual creativity to find a solution that works around the designated procedure.
The RAID™ approach is a process to analyse these incidents; the factors are analysed accross four dimensions:
- Requirement; how was the requirement of the task/function specified to
the individual
- Assignment; how was the task/function assigned to the person, did they
know it was clearly their role to act
- Inducements; were there inducements in the environment that encouraged
the person to make poor choices i.e. time pressure, pay reward on volume
not quality, past expectations that the rules would be overlooked when
under time pressure?
- Disposition; if the person was required to creatively problem-solve and find
a solution that worked around the procedure; where they experienced and
mature enough to make those decisions in an informed way?
By analysing human error in a structured way it is possible to deploy changes that will bring systemic returns. The lessons learned from a near miss can be translated to real change in the workplace and the near-miss never becomes a critical incident.
0 comments:
Post a Comment