1.0 INTRODUCTION:

Right from the day the human being appeared on this planet earth, he has engaged himself in some activity or the other – starting from gathering food to appease his hunger, up to operating the complex industry in his constant quest for progress. The most important resources of any industries are human resource which has originated the idea of industrialization for the benefit and comfort of the society and not for the harm. As industries are inevitable and some hazards are inevitable in industries, man has to learn to work with them, controlling them and taking precautions against them. Thus we see that man’s activities in industry are inextricably linked with hazards as a daily routine. In case of any mishap, chances are that he may get injured, disabled or even killed. Thousands of such mishaps are being reported and analyzed and the indications have been that nearly 88% of them have been caused by unsafe actions. In view of above, it is important to have an understanding of the role of human factors in accidents³.

A review of causes of many major global disasters (Table-1) had revealed that Human error was a key factor that had triggered the incident.

Table 1:

Sl. No.	Accident, industry and date	Human contribution and other causes
1	Three Mile Island Nuclear industry 1979 (Nuclear industry)	Operators failed to diagnose a stuck open valve due to poor design of control panel, distraction of alarms activating, inadequate operator training. Maintenance failures had occurred before, but no steps had been taken to prevent from recurring
2	Union Carbide Bhopal, 1984 (Chemical Unit)	The leak was caused by a discharge of water into a storage tank. This was the result of a combination of operator error, poor maintenance, failed safety systems and poor safety management
3	Piper Alpha 1988 (Offshore)	There was a breakdown in communications and the permit-to work system at shift changeover and safety procedures were not practiced sufficiently.
4	Chernobyl 1986 (Nuclear industry)	Causes are much debated but Soviet investigative team admitted 'deliberate, systematic and numerous violations' of safety procedures by operators
5	Space Shuttle Challenger 1986 (Aerospace)	An O-ring seal on one of the solid rocket boosters split after take-off releasing a jet of ignited fuel. Inadequate response to internal warnings about the faulty seal design. Decision taken to go for launch in very cold temperature despite faulty seal.

A Total Safety Culture (Figure 1) requires continual attention to following three areas.

1. Environment factors

2. Person factors

3. Behavior factors

Figure 1:

The assessment of safety culture is a suitable aspect for measuring key elements of safety culture and identifying an organization’s current level of development (or maturity) in order to learn and improve the safety performance¹².

Two of these categories involve human factors. Each of these generally receives less attention than the environment, largely because it is more difficult to obtain visible consequences of efforts to change the human factors. As a matter of fact:

· People design plant and equipment

· People set up systems

· People operate and maintain

· People manage

· People’s actions can lead to injuries and incidents.

Hence safety depends on people. The road to world class safety performance requires focus on human related factors which can only ensure a safe working environment rather than a narrow focus on compliances and management systems and practices.

2.0 HUMAN FACTORS IN SAFETY:

In the past the number of accidents was primary reduced by seeking Engineering and Hardware improvements. Later, it came to the conclusion, that to further decrease the number of accidents, Safety Management Systems (SMS) and procedures had to be improved.

Today, integration of HF to the knowledge of hardware and procedures is aimed at further reducing the number of accidents (Figure-2)

Figure 2:

The phrase “human factors” is often used to describe the interaction of individuals with each other, with equipment and facilities, and with management systems. It is also used to describe how such interactions are influenced by a work environment and culture.

Key human factors have been divided into following broad headings.

a. Accident causation

b. Safety awareness

c. Behavioural factors

d. Safety supervision

e. HRD interventions in safety

f. Accident investigation

g. Safety in design stage

h. Ergonomics

2.1 Accident causation:

Most of accident causation models which have been developed also suggest human factors/errors/faults/ unsafe acts as predominant cause of accidents as explained below.

a. Heinrich's Domino Theory:

HW Heinrich while employed as an Engineer with an Insurance Company in USA undertook a Study of 75,000 accident cases and formulated an understanding of the factors and process involved in accidental injury causation. This he presented in the form of model showing a linear series of interconnected causal factors. The link between the factors was demonstrated by illustrating them as dominoes so lined up that if one fell over, it would knock down the adjacent one which in turn would knock down the next and so on (Figure 3). The domino model proposes a chronological ordering of five accident factors as follows.

Figure 3:

1. Social environment

2. Fault of person

3. Unsafe act and condition

4. Occurrence of accident

5. Injury or property damage

It is evident from the above that if we wish to stop injuries then accidents must be stopped by eliminating causes i.e. preventing unsafe acts and conditions. Heinrich further indicated that 88 percent accidents are caused due to unsafe acts and 10 percent due to unsafe conditions. The study also showed that for every accident producing a major injury, there are 29 minor injuries and 300 No Injury incidents. Thus he concluded that injury prevention relied on the prevention of unsafe acts and conditions. The major portion of contributing factors to the accidents is unsafe acts which up to large extent can be attributed to human factors.

Frank E Bird and Loftus in their study in 1976, identified that lack of control by the Management would be the primary link in the chain of accident causation. A lapse in managerial control on a particular activity will result in fault of person. This lapse could be considered as the root or basic cause of accidents. This will manifest symptoms like unsafe actions or unsafe conditions. These symptoms develop further into accidents (Figure 4). The last link in the accident causation chain sequence may either be an injury or loss of property. Thus Frank Bird theory states that unsafe actions and unsafe conditions are the immediate causes or symptoms of the root cause

Figure 4:

b. Swiss cheese Accident Model:

An excellent account of this work has been provided by Reason in 1994, which emphasizes the concept of organisational safety and how defences (protection barriers such as material, human and procedures) may fail. In this approach the immediate or proximal cause of the accident is a failure of people at the “sharp end” who are directly involved in the regulation of the process or in the interaction with the technology. Reason defines accident as situations in which latent conditions (arising from management decision practices or cultural influences) combine adversely with active failures (errors and/or procedural violation) committed by individuals or teams at the sharp end of an organization, to produce the accident¹. The dynamics of accident causation are represented in the Swiss cheese model of defences (Figure-5), which shows an accident emerging due to holes (failures) in barriers and safeguards at each level.

Figure 5:

c. Modern theory of accident:

According to modern thinking, accidents require the coming together of a number of enabling-factors each one necessary but in itself not sufficient to breach system defences (Figure 6).

Figure 6:

Major equipment failures or operational personnel errors are seldom the sole cause of breaches in safety defences. Often these breakdowns are the consequence of human failures in decision making.

The breakdowns may involve active failures at the operational level, or latent conditions conducive to facilitating a breach of the system's inherent safety defences. Most accidents include both active and latent conditions.

2.2 Safety Awareness:

In the hierarchy of human needs, safety need has been placed immediately after basic physiological needs. More so the inbuilt reflex system in the human body demonstrates the quick response to safety needs. Human beings, for those matters, all living creatures on the earth do not want to expose themselves to hazardous situations, which may cause harm or injury to them. In case such situations arise, they immediately withdraw by the reflex action, which is an automatic response to the body in which thinking process is not an exercise at all.

Safety education can bring about change in safety awareness and safety attitudes⁹. Question may arise in one’s mind that in spite of being equipped with this natural Phenomenon why most people lack the desired level of awareness towards safety? The most predominant reason for this is the perception of human beings acquired through repeated observations. Heinrich and Frank Bird in their studies state that the possibilities of serious or fatal injuries are one out of 330 and one out of the 641 respectively and no visible injury or damage is observed in majority of times they committed unsafe acts or come across unsafe conditions.

This perception plays an important role for the people in adopting unsafe behaviour and therefore continuous awareness generation efforts are necessary for all level of employees. Some of research findings in this area of risk perception and risk tolerance are as follows:

· People are more likely to protect themselves when they anticipate negative consequences, oftentimes due to a previous incident, have the desire to avoid them

· People tend to take more risks when they feel a greater sense of security

· If the reward of risk taking is too great, it’s often considered “rational” to take risks.

· Engaging in high-risk behavior many times without a negative outcome often decreases the perceived risk associated with this behavior

· People take risks because of peer pressure or a general community perception that an activity is low risk.

Now, in this context, with basic human factors involved, who is in the best position to inculcate and step-up Safety awareness amongst the employees in a shop? Of course, it is the line-manager/shift I/c. It is he who assigns the job, knows the process and associated hazards and is in control of operation. He is everything for them and in short, he is their Management. He has to care for their Safety and well-being.

2.3 Behavioural Factors:

Statistics on human and equipment failure indicates that humans are at least 1000 times more likely to fail in defined behaviour requirements than is equipment.

Most of the traditional safety programs like auditing, inspections, risk assessments, training, procedures, display, safety committees, PTW etc. aims at eliminating unsafe conditions whereas majority of the incidents (88-96%) are triggered by unsafe acts/ behaviours. Common behavioural factors which can be attributed to accident causation are adopting shortcuts to save time, efforts, and money, group acceptance, ego, prejudice, over confidence, day dreaming/worries, lack of knowledge etc.

Human behavior is very complex and difficult to understand as it depends on host of factors like attitude, perceptions, motivation, culture etc. which in turn depends on heredity, socio economic background, and situational factors. A Study revealed that Change in the mind set of riders and drivers and road users realizing their responsibility alone will bring about a reduction in road accidents⁴. Another study revealed that there was a positive correlation (r=+0.314) between the knowledge and attitude of the respondent on the Road safety measures and prevention of accidents⁵. Another study found 52 % of sample population had poor knowledge about road safety prevention¹⁰.

Our beliefs also influence attitude through our value system. Moreover, behavior of a person changes with time, locations etc.

One of the models that explain what activators and consequences can trigger or motivate behaviour of the employees for safety is the ABC model (Figure 7).

Figure 7:

Antecedents:

Factors that come before behavior. They set the stage for a behavior or prompt people to act in a certain way. Examples are like rules and regulations, policies and procedures, goal setting, pledge taking, incentives/disincentives, instructions, signs, training, meeting, etc.

Behavior:

An observable act – what people do or say. As it can be observed, it can be measured and managed Contrary to attitude which cannot be visualized or managed. However attitudes can be changed by changing behaviors.

Consequences:

What occurs after a behavior and influences the likelihood of it in the future. Examples are reprimand, approvals, feedback, prize, inconvenience, time savings, comfort etc. Positive consequences for unsafe behaviour like comfort, convenience and expediency are almost certain and immediate. Negative consequences of unsafe behaviour are uncertain and futuristic. Positive, certain and immediate consequences have more influence on behaviour than negative, uncertain and futuristic consequences.

To better understand antecedents and consequences, let’s take for example a situation in which a worker reaches into a machine to clear a jam without first locking and tagging out the equipment. Why would someone break this clear safety rule? The worker has been trained, seen the standard operation procedures and been re-minded (antecedents for the desired behavior), yet still did the at-risk behavior.

First, we identify what might have prompted the worker to engage in this undesired behavior. In this case, the worker’s supervisor told him to hurry and get the equipment cleared, creating pressure on the worker. Also, he had done the same before and hadn’t been hurt. These antecedents might encourage the worker to take a shortcut.

Second, we analyze the consequences. The worker completes the task on time. His supervisor is pleased that the equipment is up and running and says so without asking how the task was completed.

Although antecedents are necessary, they aren’t sufficient. The real power for long-term performance is in the consequences. It’s important to remember that behavior is a direct result of its consequences. As long as a behavior “works” for a person, he or she will continue to do it. To change the behavior, you must change the consequences for it. Research shows that consequences have about four times more direct effect on behavior than antecedents. Yet, most organizations place four times more emphasis on antecedents than on consequences².

Motivation of behaviour towards safety can be achieved either by increasing the negative consequences of unsafe behaviour or by increasing the positive consequences of safe behaviour. Negative consequences rely on enforcement and lead to complaints and negative attitude whereas positive consequences lead to self ownership. Therefore, positive reinforcement or recognition is most convenient, inexpensive, readily available and most powerful motivator. A negative work disposition can prompt risky work propensities and accidents⁷.

2.4 Safety Supervision:

Any mishap/incident can often be traced back to the supervisory chain of commands. As such, there are four major categories of Unsafe Supervision (Figure 8)

Figure 8:

a. Inadequate Supervision: Failure to provide guidance, training and/or oversight.

b. Planned Inappropriate Operations: Failure to adequately assess the hazards associated with an operation and allows for unnecessary risk. It is also a factor when supervision allows non-proficient or inexperienced personnel to attempt critical jobs beyond their capability.

c. Failure to Correct a Known Problem: Failure to correct known deficiencies in documents, processes or procedures, or failure to correct inappropriate or unsafe actions of individuals.

d. Supervisory Violations: Willfully disregarding instructions, guidance, rules, or operating instructions.

2.5 HRD interventions in safety:

Attempting to change people safety behaviours and attitude through safety training is one of the most widely used methods of improving safety at workplace. The importance given to safety training is also underlined by legislative requirements for employers to arrange appropriate safety training for the employees. However research indicates that safety training does not bring lasting change in people’s safety related behaviours or attitudes mainly due to mismatch between training requirement and the training imparted. Examples includes:

· Inappropriate use of teaching method (e.g. lectures and presentation rather than hand on demonstrations, role modeling, role play, case studies etc.)

· Irrelevant training content/modules prepared by trainers lacking an understanding of the trainee’s jobs and lack of periodic review

· Insufficient training time to ensure real understanding of issues involved

· Use of inexperienced trainers

· Lack of feedback to individual trainees about the learning progress

Even when an ideal training program has been designed and delivered, importance of training received is often undermined through day to day operational factors (e.g. not being continually reinforced by line mangers and followed with constant coaching and refresher training). This discourages trainees to explore new ideas and utilise their newly acquired training knowledge. Since most of the training is concerned with changing people behavior by imparting particular knowledge and skills, assessment of new learning and how much it has been put to use on daily basis, is of vital importance and can be achieved by use of post training tests, assignment and evaluation of project work and actual demonstration of skill.

The degree to which learning has been put into use can also be assessed by undertaking safety management system audits at periodic interval. In absence of all these, whole training exercise becomes a sheer waste of time, money and effort.

Designing, delivering and evaluating a training course needs focused attention on all of the sequential steps given in (Figure 9). A good communication system, education and safety training of the employees, review of past accidents/reports/published safety reviews, daily site inspection etc. are the key areas of effective off-site emergency preparedness⁸.

2.6 Accident Investigation:

Yet another area where the human factor plays an important role is that of accident investigation. We all know that no safety management is complete if the accidents are not investigated. Right causes are to be found out and appropriate preventive measures are taken. But generally, the snag is that in cases where people are injured, they don’t come forward to tell the actual circumstances that lead to the accident. Firstly the injured persons who had traumatic experience and may become circumspect in an enquiry in coming out with the actual factors that led to the accident. On the other hand, in the absence of any injury, they are usually free and frank in attributing the real causes of the accident. The Manager/supervisor should therefore investigate into every incident, however minor it is, to get at the truth, for taking timely and effective preventive measures. After all, we know that any major accident occurs only after a few near-misses or minor ones take place which are usually ignored and the manager/ supervisor misses the opportunity to investigate, identify the real cause and take preventive measure in time.

After an accident involving human failure, the investigation into the causes and contributing factors often makes little attempt to understand why the human failures occurred. Finding out both the immediate and the underlying causes of an accident is the key in preventing similar accidents through the design of effective control measures.

2.7 Safety in design stage:

As mentioned above, studies of the past accidents reveal that most of all process industry accidents have human error as a causal factor. Nevertheless technical defects and management faults are often the reason for the human errors. Hence instead of trying to adapt the human to the facility, it is essential to design plants that meet the capabilities of the human.

To take human factors into account as part of the process engineering design requires design of equipment, operations, procedures and work environments in such way that they are compatible with the capabilities, limitations and needs of the human beings. This must become a vital complement to other engineering disciplines that primarily seek to optimise hardware performance and/or minimize capital costs with little or no consideration of how the equipment will actually be operated and maintained. A three-step process for addressing human error which can be incorporated into the design process is shown in Figure 10.

2.8 Ergonomics:

Ergonomics is one of the important human factors and it is recommended that a periodic review of workplace conditions and processes to be done in order to proactively identify potential issues with ergonomics. This includes looking at the facility as a whole, as well as assessing individual workstations and working practices. Workers’ compensation, injury and illness reports will also provide insight into problem areas. The danger of poor ergonomics is primarily that of musculoskeletal disorders, which are caused by repetitive motion, excessive use of bodily force, awkward posture, temperature extremes, or a combination of these factors. Operators should be able to perform their tasks in a sustained manner without excessive workload, exceptional time pressure, significantly reduced levels of alertness or the need to use novel actions or procedure⁶.

3.0 CONCLUSION:

Occupational safety a can be important for moral, legal, and financial reasons¹¹. Basically, one has to deal with the human factors to enhance safety. The thing to remember when looking at human factors is the fact that everyone in the workplace is indeed “only human.” Thus, they are fallible. Accidents can normally be attributed to one of three actions i.e. errors and unintentional mistakes, poor judgment and bad decision making and disregard for procedures. Most workplaces are adept at identifying obvious hazards and providing basic safety training upon hiring new employees. However, the evaluation of all human factors as explained in this paper should be an ongoing effort that involves all employees. Only by understanding human factors, can an occupational safety professional seek out ways to mitigate risk with stopgap measures that prevent accidents before they occur.

4.0 REFERENCES:

1. Prof. Dominic Cooper Prof. Dominic Cooper, Human Factors in Accidents, 2002

2. Behaviour Based Safety Guide, Health and Safety Authority, Govt. of Ireland Human Factors in accident Modelling, ILO

3. Rekha Thakur. A Study on road accident as a Public health issue- In terms of India. Asian Journal of Management. 2020;11(3):275-278. doi: 10.5958/2321-5763.2020.00042.6

4. Sunil Kumar Pathak. A Study to assess the Knowledge and Attitude regarding Road Safety Measures and Prevention of Accidents among two-Wheeler Teenage Riders in selected Schools and Pre University Colleges in Jaipur with a view to develop an Information Booklet. Int. J. Nur. Edu. and Research. 2018; 6(4):367-370. doi: 10.5958/2454-2660.2018.00089.3

5. Ramya K. R. Application of Human Factors and Ergonomics in Improving Patient Safety Culture. Int. J. Adv. Nur. Management. 2017; 5(4):367-371.

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8. Myung-Hyo Kang, Jong-Sik Lim, Chun-Ho Yang. Relation between Marine Safety Awareness and Marine Safety Attitudes in people experienced in Marine Safety Education. Research J. Pharm. and Tech 2019; 12(2):678-682. doi: 10.5958/0974-360X.2019.00120.3

9. Mr. Dipak Patidar, Dr. Dayalal D. Patidar, Dr. Pragna Dhabi. A Study to Assess the knowledge regarding prevention of road traffic accidents among people in Mehsana district. Int. J. Nur. Edu. and Research. 2020; 8(2):256-258.

10. Rishi Kumar Singh, Nihal Anwar Siddiqui. Assessment of Occupational, Health and Safety Problems in the Automotive Industry and their Remedial Measures. Research J. Engineering and Tech. 5(2): April- June 2014 page 54-55.

11. Sasidhar T, Abhishek Nandan, Madhuben Sharma. Assessment and Improvement of Safety Culture in a Sugar Industry in India. Research J. Engineering and Tech. 6(3): July- Sept., 2015 page 369-373. doi: 10.5958/2321-581X.2015.00057.4

Received on 07.09.2020 Modified on 24.10.2020

Asian Journal of Management. 2021; 12(1):79-85.

DOI: 10.5958/2321-5763.2021.00012.3