Human Error and Hazards in the workplace:

Human error and workplace hazards are major contributors to accidents and incidents
in organizations. Understanding the causes and management of errors and hazards is
essential for ensuring safety, maintaining productivity, and protecting employees.

Error Models and Theories

1. Introduction: Understanding Human Error

Human error refers to an unintended action or decision that leads to an undesirable
outcome, often resulting in accidents, system failures, or reduced performance. Errors
are a natural part of human behavior and occur even in highly skilled individuals.
Studying error models and theories helps us understand why errors happen, how they
propagate through systems, and how organizations can design safer processes. It
moves the focus from blaming individuals to improving system resilience.

2. Key Error Models and Theories

2.1 Reason’s Swiss Cheese Model
 Developed by James Reason in the 1990s, this is one of the most influential
frameworks for understanding accidents.
 The model visualizes defenses in an organization as multiple layers of Swiss
cheese. Each layer has holes (weaknesses).
 An accident occurs when holes in each layer align, allowing hazards to pass
through all defenses and cause harm.
 The model distinguishes between active failures (errors by frontline operators)
and latent conditions (hidden system weaknesses).
Example:
In an aircraft maintenance error, a technician (active failure) might install a component
incorrectly due to unclear procedures (latent failure).
Strengths:
 Emphasizes systemic causes rather than blaming individuals.
 Helps identify multiple failure points for accident prevention.

2.2 Skill-Rule-Knowledge (SRK) Framework (Rasmussen)

 Classifies human behavior and errors into three types:
Level Description Example

Automatic, routine tasks with little A mechanic tightening a bolt

Skill-based
conscious thought without thinking

Applying learned rules or procedures to Following a checklist during

Rule-based
familiar situations inspection

Knowledge- Using problem-solving and reasoning Diagnosing an unusual

based in new or complex situations engine fault

 Errors differ by level: slips and lapses at skill-level, rule misapplication at rule-
level, and reasoning errors at knowledge-level.

2.3 Human Factors Theory

 Human factors study the relationship between humans, machines, and
environment.
 Errors occur when design, workload, fatigue, or environment overload human
capacities.
 Key idea: poor system design increases likelihood of error (e.g., confusing
control layouts).

2.4 Active and Latent Errors

 Active errors: Immediate effects, e.g., pressing wrong button.
 Latent errors: Hidden failures, such as poor training, faulty design, or
management decisions that lie dormant until combined with active errors.

2.5 Generic Error Modelling System (GEMS)

 A cognitive model by Reason, explaining error types by mental control levels:
o Skill-based behaviour: automatic actions
o Rule-based behaviour: following stored rules
o Knowledge-based behaviour: conscious problem solving
Errors arise when behaviour switches between these modes improperly or due to
overload.

2.6 Rasmussen’s Decision Ladder

  Model describing human decision-making as progressing through gathering
information, diagnosing, choosing action, and executing.
 Errors occur when there are gaps or mistakes in any step.

3. Applications of Error Models

3.1 Accident Investigation
 Models help analysts understand root causes beyond frontline errors,
highlighting systemic weaknesses.
 Example: after a chemical spill, investigation finds poor labeling (latent error)
and operator error (active error).
3.2 Risk Assessment
 Helps organizations identify vulnerable points in processes.
 For instance, applying Swiss Cheese model to identify where safety barriers
may fail.
3.3 Designing Safer Systems
 Using human factors theory, workplaces redesign controls for ease of use.
 Training can target rule- and knowledge-based errors by teaching correct
procedures.

4. Strengths and Limitations

Model Strengths Limitations

Swiss Cheese Systemic view, visual, widely Can oversimplify complex

Model used events

Clear classification of error

SRK Framework Hard to categorize some errors
types

Human Factors Practical for design

Requires deep understanding
Theory improvements

Highlights hidden Can be difficult to detect latent

Active/Latent Errors
organizational risks errors

GEMS Detailed cognitive explanation Complex for non-experts

5. Summary
Understanding human error through models shifts the focus from blame to prevention.
Each model offers unique insight into how errors occur and propagate:
 Swiss Cheese Model highlights the layered defenses and systemic
vulnerabilities.
 SRK Framework helps identify error types based on task complexity and
behavior.
 Human Factors Theory connects error with design and environment.
 Recognizing active and latent errors helps target interventions at multiple
levels.
These models form the foundation for safer workplaces by guiding investigation,
training, system design, and policy.
Types of Error in Maintenance Tasks

1. Introduction
Maintenance tasks are critical activities performed to ensure machinery, equipment,
and systems function safely and efficiently. However, errors in maintenance can lead
to equipment failure, accidents, and costly downtime.
Understanding the different types of errors that occur during maintenance helps
organizations prevent them through better training, procedures, and system design.

2. Overview of Human Error in Maintenance

 Maintenance tasks often involve complex procedures, tight schedules, and
working with hazardous equipment.
 Errors can be unintentional (slips, lapses) or intentional (violations).
 Maintenance errors may be classified based on the nature of the mistake and
cognitive processes involved.

3. Main Types of Errors in Maintenance Tasks

3.1 Slips
 Definition: Slips are failures in the execution of an action due to attention lapses,
such as performing the wrong action or missing a step.
 Characteristics: Occur during routine or automatic tasks, where the intention
is correct but the action goes wrong.
 Examples:
o Forgetting to tighten a bolt after replacement.
o Pressing the wrong button or switch on a control panel.
o Dropping a tool inside a machine during repair.
 Causes: Fatigue, distractions, interruptions, stress.

3.2 Lapses
 Definition: Lapses are memory failures, such as forgetting to perform an action
or losing track of steps.
 Characteristics: Often related to recall of procedures or forgetting important
safety checks.
 Examples:
 o Failing to document completed maintenance work.
o Forgetting to replace a gasket or seal.
o Missing to isolate a power source before working.
 Causes: High workload, stress, multitasking, poor work environment.

3.3 Mistakes
 Definition: Mistakes occur when the intended action is wrong due to incorrect
planning or decision-making.
 Characteristics: Result from wrong assumptions, insufficient knowledge, or
poor judgment.
 Subtypes:
o Rule-based mistakes: Applying wrong rules or procedures.
o Knowledge-based mistakes: Lack of knowledge leading to
inappropriate decisions.
 Examples:
o Using the wrong lubricant for a machine.
o Following outdated maintenance procedures.
o Misinterpreting diagnostic data leading to incorrect repair.
 Causes: Inadequate training, ambiguous procedures, lack of experience.

3.4 Violations
 Definition: Violations are deliberate deviations from established procedures or
safety rules.
 Characteristics: Done knowingly, often to save time, reduce workload, or due
to perceived low risk.
 Types:
o Routine violations: Common shortcuts regularly taken.
o Exceptional violations: One-off deliberate breaches.
 Examples:
o Skipping safety lockout/tagout steps.
o Not wearing personal protective equipment (PPE).
o Bypassing a testing step to speed up work.
  Causes: Pressure to meet deadlines, complacency, poor safety culture.

4. Factors Contributing to Errors in Maintenance

Factor Description

Fatigue Long shifts and physical strain reduce attention.

Distractions Noise, interruptions, and multitasking increase errors.

Poor Procedures Ambiguous or outdated manuals confuse workers.

Lack of Training Insufficient knowledge leads to mistakes.

Work Environment Poor lighting, cramped spaces impair task performance.

Time Pressure Rush to complete jobs encourages shortcuts and errors.

Communication Gaps Incomplete handovers cause misunderstandings.

5. Examples of Maintenance Errors and Their Consequences

Error
Example Consequence
Type

Slip Technician forgets to reattach guard Exposure to moving parts, injury risk

Lapse Power not isolated before repair Electric shock or equipment damage

Mistake Wrong part installed Machine breakdown, costly repairs

Skipping inspection after

Violation Undetected faults leading to failure
maintenance

6. Managing Maintenance Errors

 Recognizing the types of errors helps target interventions:
o Use checklists to reduce slips and lapses.
o Provide clear, updated procedures to minimize mistakes.
o Foster a safety culture to discourage violations.
 Encourage reporting of near misses to learn from errors without blame.
 Design ergonomic tools and environments to reduce physical and cognitive
strain.
8. Summary
Maintenance errors fall mainly into slips, lapses, mistakes, and violations. Each type
has distinct causes and requires different prevention strategies. By understanding
these error types, organizations can design safer maintenance systems, improve
training, and reduce accidents and downtime.
Implications of Errors (Accidents)

1. Introduction
Errors in the workplace, especially in maintenance and operational tasks, often lead to
accidents. An accident is an unplanned event that results in injury, illness, property
damage, or environmental harm. Understanding the wide-ranging implications of these
errors is crucial for promoting safety and risk management.

2. Types of Implications from Errors and Accidents

A. Physical Implications: Injuries and Fatalities
 Errors can cause minor injuries (cuts, bruises), major injuries (fractures, burns),
or fatalities.
 Example: Forgetting to lock out a machine before maintenance leads to severe
injury.
 Injuries affect employees’ health and well-being, often requiring medical
treatment and rehabilitation.
B. Psychological Implications
 Accidents cause stress, anxiety, and trauma for victims, witnesses, and
coworkers.
 Fear of repeating errors may reduce confidence and morale.
 Post-accident trauma can lead to absenteeism and reduced productivity.
C. Financial Implications
 Direct costs: Medical expenses, workers’ compensation, fines, repairs, and
replacements.
 Indirect costs: Lost workdays, decreased productivity, training replacements,
investigation costs.
 Example: A machinery accident halts production, causing financial losses and
penalties.
D. Legal and Regulatory Implications
 Workplace accidents may violate health and safety laws.
 Organizations may face fines, sanctions, lawsuits, or forced shutdowns.
 Failure to comply damages reputation and can cause long-term business
impacts.
E. Operational Implications
  Accidents often lead to downtime and disruption of normal workflows.
 Maintenance errors causing equipment breakdown may halt production lines.
 Delays and reduced efficiency increase operational costs.
F. Environmental Implications
 Some errors cause hazardous spills, fires, or emissions harming the
environment.
 Environmental damage may attract legal action and clean-up costs.
 Example: Chemical leak from improper valve closure contaminates soil and
water.

3. Case Study Examples of Accident Implications

Case 1: Industrial Machinery Accident
 A maintenance technician forgets to isolate power.
 Consequence: Severe injury to the technician, costly medical bills.
 Production halted for investigation and equipment repair.
 Legal fine imposed for safety violations.
 Company reputation affected negatively.
Case 2: Chemical Plant Leak
 Operator skips safety check (violation).
 Consequence: Chemical leak causes environmental contamination.
 Clean-up costs run into millions.
 Regulatory scrutiny intensifies; operational license reviewed.

4. Broader Implications for Organizations

A. Loss of Reputation and Customer Trust
 News of accidents damages public image.
 Clients and customers may switch to competitors.
 Recruitment of skilled workers becomes harder.
B. Impact on Safety Culture
 Frequent errors and accidents can indicate poor safety culture.
 Employee engagement and reporting decrease if blame culture exists.
  Organizations struggle to maintain safety standards.
C. Insurance Costs
 Accidents increase insurance premiums.
 In severe cases, coverage may be denied or limited.

5. Implications for Employees

 Fear and stress from accidents may affect work quality.
 Injured workers may face long recovery periods or disability.
 Career disruptions and financial hardship may follow.

6. Preventing Negative Implications

 Proactive error management and safety programs reduce accident risk.
 Strong safety culture encourages reporting and learning from near misses.
 Training and competence development build safer work practices.
 Investing in technology and human factors engineering improves safety.

7. Summary
Errors leading to accidents have far-reaching implications beyond the immediate injury.
They impact individuals’ health and morale, impose financial and legal burdens on
organizations, disrupt operations, and may damage the environment and reputation.
Understanding these consequences motivates organizations and employees to
prioritize safety, adopt robust error management, and foster a positive safety culture.
Avoiding and Managing Errors

1. Introduction
Errors are a natural part of human activity, but in the workplace—especially in
maintenance, manufacturing, healthcare, and other high-risk environments—they can
have serious consequences. Avoiding and managing errors effectively is critical for
safety, productivity, and quality.
This topic covers strategies and best practices for reducing the occurrence of errors
and managing them when they do occur.

2. Avoiding Errors: Proactive Strategies

2.1 Training and Competency Development
 Regular, comprehensive training ensures employees understand tasks,
equipment, and safety procedures.
 Training reduces mistakes caused by lack of knowledge or skills.
 Simulation and hands-on practice help prepare employees for real situations.
 Example: Maintenance workers trained on lockout/tagout procedures are less
likely to make power isolation errors.
2.2 Clear and Standardized Procedures
 Develop detailed, easy-to-understand work instructions and checklists.
 Standardized procedures reduce ambiguity and ensure consistent task
execution.
 Use visuals, flowcharts, and step-by-step guides.
 Example: An aircraft maintenance checklist ensures all critical steps are
followed.
2.3 Human-Centered Design
 Design tools, controls, and workspaces that match human capabilities and
limits.
 Reduce complexity, eliminate confusing controls, and improve ergonomics.
 Example: Color-coded valves or buttons reduce the chance of operator error.
2.4 Environmental and Organizational Factors
 Manage work conditions to minimize fatigue, distractions, and stress.
 Encourage adequate rest breaks and limit overtime.
  Foster a positive safety culture where employees feel comfortable reporting
issues without fear of blame.
2.5 Use of Technology and Automation
 Automation can reduce repetitive tasks prone to human error.
 Warning alarms, interlocks, and error-proofing mechanisms (poka-yoke) can
prevent errors.
 Example: Automatic shutoff systems in chemical plants reduce the risk of spills.

3. Managing Errors: Reactive Strategies

3.1 Error Reporting Systems
 Encourage employees to report errors and near misses openly.
 Non-punitive reporting builds trust and increases reporting rates.
 Analyzing error reports helps identify patterns and system weaknesses.
3.2 Incident Investigation and Root Cause Analysis
 Investigate errors and accidents thoroughly.
 Identify underlying causes, including latent conditions.
 Use tools like the 5 Whys, Fishbone Diagrams, and Swiss Cheese Model to
analyze errors.
3.3 Corrective and Preventive Actions
 Implement changes to address root causes and prevent recurrence.
 Actions may include revising procedures, retraining, or equipment modification.
3.4 Continuous Improvement
 Foster ongoing review and refinement of processes.
 Encourage feedback loops from workers to management.
 Apply quality management principles like PDCA (Plan-Do-Check-Act).

4. Balancing Accountability and Learning

 While individuals must take responsibility, organizations should focus on
system improvements rather than blame.
 A just culture balances learning and accountability.
 Punitive responses to honest mistakes discourage reporting and increase risk.
5. Examples of Error Avoidance and Management in Practice

Strategy Example

Training Regular refresher courses on safety and procedures

Standard Procedures Maintenance checklists and sign-offs

Human-Centered
Intuitive control panels with fail-safe features
Design

Reporting Systems Anonymous online error reporting platforms

Investigating why a valve was left open and fixing training

Root Cause Analysis
gaps

7. Summary
Avoiding and managing errors requires a comprehensive approach involving training,
clear procedures, good design, supportive culture, and continuous learning. While
errors cannot be eliminated entirely, their frequency and impact can be greatly reduced
with the right strategies. Building a just culture encourages openness and continual
improvement, ultimately creating safer and more effective workplaces.
Recognizing and Avoiding Hazards

1. Introduction
A hazard is any source, situation, or condition that has the potential to cause harm,
injury, or damage to people, property, or the environment. Recognizing hazards is the
first step toward preventing accidents and creating a safe workplace.
Avoiding hazards involves identifying, assessing, and controlling risks to protect
workers and operations.

2. Types of Workplace Hazards

2.1 Physical Hazards
 Include slips, trips, falls, moving machinery, noise, radiation, and extreme
temperatures.
 Example: Wet floors that can cause slips or unguarded machinery parts.
2.2 Chemical Hazards
 Exposure to harmful substances like acids, solvents, gases, or dust.
 Can cause burns, poisoning, respiratory problems.
 Example: Handling cleaning chemicals without proper PPE.
2.3 Biological Hazards
 Bacteria, viruses, fungi, or other organisms that cause illness.
 Common in healthcare, laboratories, and waste management.
 Example: Exposure to bloodborne pathogens.
2.4 Ergonomic Hazards
 Poor workstation design causing repetitive strain, poor posture, or
musculoskeletal injuries.
 Example: Heavy lifting without support or poorly adjusted chairs.
2.5 Psychosocial Hazards
 Stress, workplace violence, harassment, fatigue, or bullying.
 Can affect mental health and job performance.
 Example: High work pressure causing burnout.

3. Recognizing Hazards: Methods and Tools

3.1 Workplace Inspections
 Regular, systematic walkthroughs to spot potential hazards.
 Check machinery, storage areas, walkways, lighting, and safety equipment.
3.2 Risk Assessments
 Identify hazards, evaluate their risk level (likelihood and severity), and prioritize
control measures.
 Often use risk matrices or scoring systems.
3.3 Incident and Near Miss Reports
 Analyse past accidents and near misses to identify hazard patterns.
3.4 Employee Involvement
 Encourage workers to report hazards and unsafe conditions.
 Use suggestion boxes, safety committees, and meetings.
3.5 Job Safety Analysis (JSA)
 Break down tasks step-by-step to identify hazards at each stage.
 Develop safe work procedures accordingly.

4. Avoiding Hazards: Control Measures (Hierarchy of Controls)

The Hierarchy of Controls ranks methods from most to least effective:
4.1 Elimination
 Remove the hazard completely.
 Example: Replacing a toxic chemical with a safer alternative.
4.2 Substitution
 Replace the hazard with something less dangerous.
 Example: Using water-based paint instead of solvent-based.
4.3 Engineering Controls
 Isolate people from the hazard.
 Example: Machine guards, ventilation systems, noise barriers.
4.4 Administrative Controls
 Change how people work.
 Example: Job rotation, training, signage, safe work procedures.
4.5 Personal Protective Equipment (PPE)
  Provide protective gear such as gloves, helmets, goggles.
 Considered the last line of defense.

5. Best Practices for Hazard Recognition and Avoidance

 Conduct regular training on hazard awareness.
 Maintain clear, accessible hazard reporting systems.
 Keep workplaces clean and organized.
 Review and update risk assessments periodically.
 Communicate hazards clearly using signs and labels.
 Encourage a safety-first mindset at all organizational levels.
6. Examples of Hazard Recognition and Avoidance

Hazard Type Example Scenario Control Measure

Physical Wet floor in production area Warning signs, proper floor cleaning

Use of PPE, ventilation, substitution if

Chemical Handling strong acids
possible

Repetitive assembly work

Ergonomic Job rotation, ergonomic tools
causing strain

Psychosocial High workload causing stress Workload management, counseling

8. Summary
Recognizing hazards is vital to preventing accidents and protecting workers. Using a
structured approach—inspections, risk assessments, and employee involvement—
helps identify hazards early. Applying the hierarchy of controls effectively minimizes
risks, creating safer workplaces.
Dealing with Emergencies

1. Introduction
Emergencies in the workplace are unplanned and dangerous events that threaten the
health, safety, and lives of people, as well as property and the environment. They can
happen suddenly and require immediate and coordinated action.
Being prepared to deal with emergencies is a legal, ethical, and operational necessity
in all organizations. Effective emergency management can minimize harm and even
save lives.

2. Types of Workplace Emergencies

Type Description & Examples

Fire Emergencies Electrical fire, flammable material ignition, kitchen fire

Medical Emergencies Heart attack, fainting, severe injury, allergic reaction

Chemical Spills/Leaks Exposure to hazardous materials or toxic gas release

Electrical Incidents Shock, electrocution, explosion due to electrical fault

Natural Disasters Earthquake, flood, storm, heavy rain or snow affecting safety

Workplace Violence Aggression, assault, or security threat from intruders

Structural Failures Roof collapse, falling objects, machinery malfunction

3. Stages of Emergency Management

Emergency management is usually divided into four key stages:
3.1 Preparedness
 Involves planning, training, and developing emergency procedures before an
event happens.
 Includes:
o Creating Emergency Action Plans (EAPs)
o Identifying emergency exits and assembly points
o Conducting emergency drills (fire, evacuation, lockdown)
o Assigning responsibilities (e.g., fire wardens, first aiders)
o Stocking emergency supplies (first aid kits, fire extinguishers)
3.2 Response
 The immediate action taken once an emergency occurs.
 Objectives:
o Ensure safety and evacuate or shelter in place.
o Alert emergency services.
o Provide first aid and basic support.
 Requires calm, clear communication and rapid coordination.
3.3 Recovery
 Restoring operations and returning to normalcy after the incident.
 Actions include:
o Repairing damaged property
o Providing support and counseling to employees
o Conducting debriefings and evaluations
o Documenting incidents for reporting and insurance
3.4 Mitigation
 Long-term measures to prevent future emergencies or reduce their impact.
 Examples:
o Installing fire suppression systems
o Improving structural safety
o Training staff in hazard awareness and emergency response

4. Emergency Response Procedures

A. Evacuation Procedure
1. Sound alarm and alert others.
2. Shut down equipment if safe to do so.
3. Follow exit routes posted in the workplace.
4. Do not use elevators.
5. Assemble at the designated safe zone.
6. Conduct a roll call or headcount.
7. Wait for the all-clear signal before returning.
B. Fire Emergency
 Raise the alarm and use fire extinguisher if trained and safe.
 Evacuate immediately.
 Avoid inhaling smoke—crawl low if necessary.
 Close doors behind you to prevent fire spread.
C. Medical Emergency
 Check the scene for safety before approaching.
 Call emergency services immediately (e.g., 999 / 911).
 Apply first aid if trained.
 Stay with the injured person and provide reassurance.
D. Chemical Spills
 Evacuate the area and alert emergency services.
 Do not attempt to clean unless trained and properly equipped.
 Shut off ventilation if safe to do so.
 Use spill kits, wear PPE if handling.

5. Roles and Responsibilities in an Emergency

Role Responsibilities

Employees Follow instructions, evacuate safely, report to supervisors

Supervisors Ensure area is clear, report missing persons, assist first aid

First Aiders Provide immediate medical support

Fire Wardens Guide evacuations, use extinguishers if needed

Management Coordinate with authorities, communicate with stakeholders

6. Emergency Communication
 Use clear, calm, and direct language.
 Use radios, PA systems, mobile alerts, or alarms for notification.
 Display emergency contact numbers prominently.
 Keep updated employee contact lists.
7. Training and Drills
 Conduct regular fire drills, spill response exercises, and medical emergency
simulations.
 Evaluate response time, clarity of instructions, and crowd behavior.
 Update procedures based on drill outcomes.

8. Common Emergency Equipment

 Fire extinguishers (ABC type)
 First aid kits
 Spill kits (chemical absorbents, neutralizers)
 Defibrillators (AEDs)
 Emergency lighting and exit signage
 Alarms and PA systems

9. Real-World Examples
 Grenfell Tower Fire (UK, 2017): Lack of clear evacuation plan resulted in major
casualties.
 Bhopal Gas Tragedy (India, 1984): Chemical plant leak led to thousands of
deaths—no emergency preparedness.
 Taiwan Earthquake (2016): Companies with rehearsed disaster drills saved
more lives than those without.
10. Summary
Dealing with emergencies requires planning, preparedness, and calm execution. Every
workplace should have clear procedures, trained personnel, and equipment to respond
effectively. Training, communication, and a strong safety culture ensure employees are
ready to act confidently in crisis situations.