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Everyone makes mistakes….

 Does anyone leave the house thinking…
today I will have an accident?
 Does anyone go to work thinking… I
hope I slip over today?
 Is there anyone on a worksite thinking…
I’ll take a shortcut as I expect that will
injure me or someone else?
 Who feels that having an accident is a
good thing?
 Have you ever thought, I really enjoy
increasing the risk I am exposed to?

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And yet….  We all make mistakes
 Sometimes we forget to do things
 We think we have to take shortcuts to get
a job done
 Sometimes things slip our minds and get
missed
 We might have to improvise if it’s a
situation we are not familiar with
 It’s human nature… but why do our brains
make us do this?

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Are all mistakes the same?
 No! They happen for different reasons
 There is a difference between an Error and a
Violation
 Error: An action which was NOT intended
 Violation: Intentionally NOT sticking to
rules

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Different type of errors…
Errors have 2 types: Slips & Lapses
 Slips are related to failure in our memory
e.g. thinking you mustn’t forget to bring
something with you to site - only to arrive at
site without it? Ever done that?
 Lapses are related to failure in our attention
e.g. you’re listening to a safety brief and you
‘zone out’. This is influenced by alpha state.

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What influences the likelihood of
errors occurring?
 There are a number of different factors which
can increase errors:
 High or low workload
 Fatigue
 Poor training
 Lack of experience or supervision
 Poor quality work environment
 Individual character traits
 Other things on your mind

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And all these factors…!!
INDIVIDUAL
STRESSES RULES AND REASONS
Time pressure PROCEDURES Capacities
Workload Accuracy Training
High risk environment THINGS IN THE How clear they are Experience
Repetition ORGANISATION Meaning Skills
Fatigue, pain, discomfort Manning / rostering Ease of use Knowledge
Conflict Work hours/breaks Applicability Personality
Distractions Resource availability Amount of detail Physical fitness
Shift work Actions of others How up to date they are Attitudes
Incentives Social pressures Motivation
Organisational structure
Team set up
THE JOB OR TASK Communication DEMANDS OF
Authority WORK THE JOB
Frequency ENVIRONMENT
Repetitiveness Responsibility Physical
Group practices Temperature Memory
Workload Noise
Criticality Rewards and benefits Attention
Vibration Vigilance
Continuity Lighting
Duration

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So what’s a violation…part 1?
It’s when we know we are breaking a
rule but we do it
for a number of reasons…
Routine
 If we have frequently broken the
rules, and no-one appears to mind,
it becomes a normal way of
working.
 Why? It saves time, maybe the
rules are too restrictive or there is a
lack of rule enforcement, new
workers accepting old ways of
working e.g. do you ever go over 70
on the motorway?
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So what’s a violation…part 2?
Situational
 Where people break the rules on a certain task as a
one off because of pressures from the job.
 Why? Due to time pressure, workload, rules are
considered to be unsafe in some conditions e.g.
Have you ever made a call when you're driving and
you don’t have a hands free kit?
Exceptional
 In an emergency a person is forced to violate despite
good intention.
 Why? The benefits outweigh perceived risk e.g. do
you always return all your tools to the correct place
if you need to get home quickly?

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So what’s aOptimising
violation…part 3?
 Working around rules for personal
gain.
 Why? Finishing work early, getting
home quickly, disregarding rules as not
perceived as important e.g. do people
always call the Signaller to cross the
track on a straight piece of track with
good sighting distance?

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That’s all interesting enough but
what do we do about it (1)?
Different types of violations require
different fixes.
Routine
 Remove unnecessary rules, revise
identified rules to make them practical
and usable, improve site design to make it
easier for people not to take shortcuts or
improve reporting of violations to learn
why people do it
Situational
 Establish positive safety culture

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That’s all interesting enough but
what do we do about it (2)?
 Exceptional
 Provide awareness of dynamic risk
assessment, support other staff
 Optimising
 Support staff and raise awareness of
likelihood of optimising violations near
ends of shift, increase supervision
 What else do you think you can do?

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So if we all violate what’s the
problem?
 Although we all do it sometime
in our working lives, there are
dangers with violations.
 Will you know what someone is
going to do next if you are not all
working to the same rules? Be
careful about making
assumptions
 If rules are routinely violated
then it devalues the rules – how
do we decide what is
unbreakable and what can be
flexed?

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How do we make a change?
 Reducing errors and violations takes more than disciplinary
action…

 More effective working comes from:

 Designing sites to be laid out correctly to reduce shortcuts

 Changing procedures and rules to be more usable and

easy to apply and stick to

 Checking your training to make sure people KNOW what

the rules really are

 Improving attitudes towards both work and rules /

procedures

 Providing supervision where required to stick to the rules

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Reaction… the most important
management technique
 So, we agree that no-ones goes to work to have
an accident and no-one really wants to injure
themselves or their colleagues at work.
 So why, when something goes wrong,
someone makes a genuine mistake or violates
a rule to get the job done, do you;
 React with anger?
 Blame them?
 Think they’re idiots?
 Remember, the most important thing to do is
make sure they are ok, ask them why they did it,
what could be learnt next time?

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So what did we learn?
 That people make mistakes
 That errors are an unintentional
failure to carry out a task successfully
 That violations are different and that
they are an intentional breaking of
the rules to get a task done
 The different types of violations
occur for different reasons and
require different ‘fixes’
 That the most important lesson is to
understand why people made an
error or made a violation, not to
blame them for it

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