Human factors analysis is designed to expose the roles that humans play in accidents, incidents, high-potential events and near misses.

It teaches that error is not failure. Recent studies indicate that up to 90% of mishaps and incidents are due to human error and that 100% of incidents involve some form of human factors.

Yesterday I was speaking with a friend who told me about an incident they had at work earlier in the week. A young employee injured himself while attempting to collect some caustic material in a bucket. He was trying to collect a sample from a drain point on a high-pressure pipe (not the low-pressure sample point specifically designed for this purpose). When he opened the valve, he was sprayed in the chest and face with caustic material. What I found interesting was the conclusion my friend had jumped to right away—that the young employee was foolish and should have known better. After the conversation, I couldn’t help but think “why should he have known better”, as that would presume he was trying to get injured.

In this case, the better presumption would be the employee did not perceive there to be any risk in what he was doing. This made me think of the American sociologist William Isaac Thomas and his theorem which states “facts do not have a uniform existence apart from the persons who observe and interpret them.” In other words, perception is everything when trying to understand why people make certain decisions and take certain actions. So, to truly understand what happened here and why, we need to understand the employee’s perspective of the situation and what informed his decisions leading up to the accident.

As a leader or investigator, this concept is important to you for two reasons:

In the end, it is imperative to look at an incident from the employee’s perspective to learn what are the decisions he made leading up to the incident. Once you do this, you will have a deeper insight that will lead to broader solutions that will prevent impending disaster before it occurs.