At the end of last month, Alton Towers released a report stating that the incident on 2nd June, in which the ‘Smiler’ ride crashed injuring 16 people, was caused by ‘human error’. The reaction from human factors experts was immediate, with many posting on social media expressing exasperation that human error was once again being used as a catch-all explanation for a serious incident. The common viewpoint was that the term human error obscures the true causes of an incident and prevents an organisation from properly addressing them. A number of commentators mentioned a need to publicise the work of human factors experts, particularly the work they do to understand and prevent accidents, so that the public no longer accepts the human error explanation.
As highlighted very clearly by the articles in this month’s issue of The Ergonomist, ergonomics and human factors professionals are not interested in pinning accidents on one person. Instead, they strive to understand how the systems and processes already in place in an organisation might create conditions where errors can occur. Not only that, but they provide practical solutions to reduce risk and to ensure that, even when things do go wrong, they don’t escalate and lead to disaster.
Jonas Lundberg and Billy Josefsson discuss the reasons why investigators overlook or fail to analyse risk, causing ‘blind spots’ to appear in accident investigations, and what can be done to help eliminate them. Lance Holman describes the painstaking process by which a simple but essential hospital procedure – the ward round – was analysed and changed based on feedback from staff in order to improve patient care. And Laurent Karsenty and Christian Neveu outline the workshops they have carried out with rail managers in order to develop a safety culture, with an emphasis on building and reinforcing trust relationships.
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If you work in ergonomics and human factors, and would like to write for The Ergonomist, contact our editor, Frances Brown: firstname.lastname@example.org. Join the debate on Twitter (@CIEHF) and on Facebook.