In my opinion incidents are seldom the result of human error when properly analysed, I find human error is a classic example of something which tries to answer everything and in trying to do so answers nothing. Human error is often attached to systemic failures, including inadequate management oversight, a safe system of work which is not fit for purpose, commercial pressure over riding safety management, inadequate training, poor work control, bad design and ergonomics and much else. I'm struggling to think of an incident I've investigated for which I'd make human error a principal cause, though I can remember many where the initial reaction of many was to blame human error.
I have been investigating accidents for decades.
I 'properly analyzed' all MSAH and OSHA fatalities since 1990 to develop a new safety law and >90% were human error by the victim.
Lockout/tagout/verify absence of V
They all had training
The engineering controls were in place
The individual is responsible for his work habits and personal safety
LO/TO/verify is drilled into them
In fact if observed by an inspector, they are cited and lose their papers
If by management, disciplined, and if repeated, terminated
We have to stop blaming others for our actions.
If you have never investigated an accident where the victim caused his fatality you have never investigated an accident.
What agency do you work for?
I am the principal in charge of investigating accidents for a state LE Bureau, I supervise Inspectors.
Example:
The last one.
Power centers have l cover switches.
When a cover is removed it trips the upstream feeder.
A worked removed a cover.
He then jumpered out the switch
He reset power
He then stuck his arms into the internals
12470/7200, bad result
He broke the law bypassing safety devices. He was troubleshooting the switches. That could be done de-energized.
He had 20 years experience
A certified electrician
A supervisor who conducted safety training
It was an off shift, no production pressure