Expert Commentary

Human Error Considerations in Construction Project Delivery

Safety performance management invariably revolves around improvement interventions that are primarily focused on the workers and the physical work environment. To some extent, physical hazards are identified, and some physical controls are implemented. Some organizations do a better job in this area than others, but none are completely and totally effective. To enhance the safety statistics—as well as outcomes—workers are provided training to ensure that they are aware of the governing safety standards as well as any rules the organization may have concerning safe work practices.


Construction Safety
October 2015

If the resulting outcomes are not satisfactory to the extent that they do not meet expectations, the workplace is rigorously inspected, and workers are retrained. If this priority effort does not garner the expected results, workers are given refresher training, and they are also subjected to incentive or punishment programs. Sadly, this still does not result in the elimination of incidents and achievement of the expected results.

The Issue of Control

The underlying assumption is that workers have total control over their behavior at work. The reason for providing the safety standards training is to ensure that workers have the information to make the "correct" choices while they are performing the work. There is also the thinking that workers may forget this, which leads to the retraining to ensure they have the necessary knowledge. Some organizations also have come to understand that workers may not pay as close attention to their work as may be needed at times, so they implement refresher training and more inspections.

At a few organizations, management has divined that there are states of mind that may increase the worker’s chances of making errors, which may lead to incidents. Some of these states include rushing at work (may increase the risk of injury) and overfamiliarity with a task (may result in boredom or complacency), which can increase the potential for at-risk behaviors. So, these organizations have implemented programs to teach workers to focus on their work more closely. This may be a little too much to expect of workers who already may have too much on their proverbial plate, and more importantly ignores basic human mental processes.

Along the same lines is the thinking that if workers were better able to assess their exposure to risks that may cause injuries while they are engaged in the work, then they should be able to more effectively make the correct choices so as to avoid getting injured. This means the worker will not only have to be completely focused and be fully engaged in the task, but to also be able to assess the situation, the degree of exposure, and its extent as well as the seriousness of the risk. After which, they should have the ability to make a determination as to their ability to effectively deal with the given situation while performing the task. This is probably not a very realistic expectation either.

Another area considered by some companies is to try to change their worker’s undesirable work habits or practices. This involves a long-term commitment as it takes some time to accomplish. The worker will have to be told what the "right way" for performing the task is. Then they will have to be fairly closely observed and given feedback on their performance. Though this may work for some industries, it is more challenging in construction due to the variability in the work, and—more importantly—the transient nature of the workforce. Not that changing work habits is not important, but at a more basic and practical level ensuring that the operational systems and work processes support safe performance of the work is in management's control, simpler to implement, garners some improvement results, and set the stage to ensure greater success if and when behavior interventions are attempted.

Another tactic is to try to analyze "near misses" so as to determine what lead to the event. The thinking behind this is that a careful analysis of such events should identify the conditions or actions that lead to the event and therefore enable the organization to take steps to stop them from occurring in the future. Though this particular avenue may provide some useful information, it may not be as effective as the organization believes it to be in eliminating future similar incidents. Why? The conditions involved in that particular event will probably never be repeated exactly in the same way or in the same sequence; the contributing factors are invariable going to be somewhat different. As a result, whatever is put in place may be somewhat effective or not effective at all at some future point.

Seeking Interventions

All these tactics and interventions garner some improved results in the short term. Some are based on the fact that they do address some of the potential underlying causes of the problem. Some improvement comes from the fact that attention is paid to the work process or practice as discovered at the Western Electric plant almost a century ago (see the Hawthorne effect). They highlight the lack of correlation between the intervention implemented and the temporary improvement outcomes. These efforts do not achieve the results expected in the short term and virtually garner nothing in the long term.

To address the potential for risk taking on the part of the worker while performing their tasks, organizations have tried a few different interventions. One approach is to try to get the worker more attuned to their work environment as well as to their state of mind. The thinking behind this is that this should lead the worker to be able to recognize he or she moves into such states of mind and thereby consciously tries to take steps to pay greater attention to the work so as to avoid the possibility of doing something that will cause an injury.

One of the realities of human endeavor is the fact that errors are made during the course of the work in spite of all of the above efforts on management’s part. No amount of training, oversight, coaching, incentive, or punishment, will eliminate human error. What is overlooked in many cases is the fact that many management systems and operational procedures are error provocative, which confounds the safety practitioners and compounds the unacceptability of the safety performance issue. Designing management systems to deal with human error is a major challenge for organizations that are serious about eliminating or even reducing accidents, injuries, and losses at their worksites. One does not have to look long or hard to find case after case where human error has resulted in costly and even deadly outcomes. In many instances, these tragic results can be traced back to the systems within which the workers had to operate to accomplish their work.

The Management System

The management system is a set of interconnected and interdependent parts forming the integrated whole. In a broad sense it includes policies, procedures, practices, processes, strategies, goals, objectives, metrics, etc. It is how things are done in that organization or at that worksite. It influences how people interact, how they go about doing their jobs, what they think is important or expected of them. This may be the result of subsystems not being fully integrated, goals out of alignment with capabilities or resources, the infrastructure and technology may create performance barriers, etc. The list goes on and on.

Management systems can be designed to more effectively deal with potential human error and either prevent the serious negative outcomes of at least reduce the undesirable consequences to a more acceptable level, thereby saving time, money, and—more importantly—reduce injuries and losses.

What may be of greater interest to management is that every time a worker makes an error, the worker does not necessarily get injured, but productivity decreases or the quality of the work deteriorates. Upon discovering their error, workers have to go back and correct the discrepancies. This takes time, and makes them less productive, which ultimately impacts both cost and schedule. If they do not discover the error and proceed with the work, and the discrepancy is discovered later, the completed work may have to be undone or removed and replaced, taking even more time and costing more money. This sort of thinking put the approach to performance management into a completely different arena.

The Distraction Problem

Workers may function in either a focused state of mind or in a distracted state of mind while engaged in their work. (see Figure 1). Ideally, the work should be performed when the worker is fully focused on the task at hand. But, for all practical purposes, their mind may wonder for any number of reasons. In fact, staying focused on a single thing for an extended period of time is not an easy endeavor. The length of time one can stay focused on one activity varies from person to person, situation to situation, and is influenced by a multitude of factors. Some of the factors are related to the task, some to the work climate, and some to the worker's personal situation, to name a few. Performance and Worker's State of Mind

Figure 1—Performance and Worker’s State of Mind

Getting distracted is a natural occurrence. Distractions primarily come in two main types. They are either sensory distractions or emotional ones. The sensory distractions come from the environment. Emotional distractions come from our thoughts. Emotional distractions can come from something we heard, felt, or experienced (our reaction to things that happen to us in our private or work life). The emotional distracters are by far more powerful that the sensory ones. The problem with emotional distracters is that they cannot be fully set aside, as the mind will try to find a resolution to them, and therefore the person tends to fall into and for all practical purposes somewhat stays in the distracted state. When workers are distracted, they are more likely to make an error.   

A worker may make an error whether they are focused on the task or distracted, though they are more likely to make an error when they are distracted. The key factor is whether the worker becomes aware that an error was made and how soon after it was made that they become aware of it. The longer the worker works in a distracted or at-risk state or situation, the greater the likelihood of an adverse outcome.

Dealing with the Error-Prone State

Workers Mental State and the Error Perspective

Figure 2—Workers Mental State and the Error Perspective

Understanding that workers are going to be functioning in an error-prone state at work, it should become rather obvious that the traditional safety interventions are not going to be effective in remedying this particular situation. Management must try to find more effective means of dealing with this fundamental issue. An effort in making the work process less error provocative may be a useful avenue to pursue. One way is to create a detailed characterization of the procedures that the worker must follow. This reveals details of what the worker must learn, do, and remember during normal task execution.

In some experiments, it was found that errors occurred anywhere from 25 to 50 percent of the time in many occupational settings. This indicates the pervasiveness of human error and the importance of designing means and methods that accommodate them with minimal adverse effect. The error recovery process follows a common path:

  1. A mistake is made.
  2. The mistake is identified.
  3. The worker resets the process.
  4. The error effect is corrected.
  5. Error-free work is resumed.

Another finding in a number of experiments was that error occurrence and its correction on average increased the time it takes to perform the task by approximately 50 percent. If the error requires some level of problem-solving, the time increased even more. The additional time required depends on the complexity of the problem-solving process. These experiments highlight the fact that the recovery process must be efficient and effective to significantly reduce the time required to correct the situation.

The resulting outcome of the error in the project delivery process may be that either the production process is impacted which results in reduced efficiency, the quality of the work is impacted and potentially may require correction or replacement, or the worker may get injured in the process and impact safety. The economic impact of the error is more likely to affect efficiency than the other two outcomes. Research has found that a worker can work unsafely for a long period of time (about 7 years) and not get injured because of the risk-taking behavior. The traditional way the project delivery process is designed and carried out, human error consideration is not well addressed at best or ignored at worst. For dealing with human error in the project delivery process, see my articles Innovations in Construction Safety—Error Proofing (August 2012) and Performance Management and the Human Error Factor (December 2010).

Conclusion

Achieving good results in the area of production, quality, and safety are primarily the result of the physical efforts of the worker. But, for the worker to perform well, they have to operate effectively within the organizational and operational systems. For the systems to enable such performance, they have to be aligned and integrated, resilient, foster goal achievement, prevent human error where possible, be error intolerant, and enhance the flow of resources and information. Management must map the processes to identify constraints and barriers, effectively plan and manage risk, as well as create a climate of trust and cooperation fostering empowerment and engagement resulting in optimal performance.


Opinions expressed in Expert Commentary articles are those of the author and are not necessarily held by the author's employer or IRMI. Expert Commentary articles and other IRMI Online content do not purport to provide legal, accounting, or other professional advice or opinion. If such advice is needed, consult with your attorney, accountant, or other qualified adviser.

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