Experts don't make good trainers. Most experts at a job are not good people to train in new people because the expert tends not to know the dangers they avoid.
An expert machine operator can omit to tell a trainee of a danger. What appears obvious to the expert is not obvious to the novice. Indeed, the expert might not even be conscious of a danger they automatically avoid.
Ms Patricia Murray, an inspector with the Health & Safety Authority (HSA) and an occupational psychologist, commented on the limitations and risks of using experts as trainers following a pilot project she conducted of 40 accidents in the Irish workforce investigated by the HSA.
She was speaking at last week's annual conference in Athlone of the Irish branch of the Institution of Occupational Safety and Health (IOSH), which has grown in recent years to 700 members. If work is set up so that, without anyone making any mistakes, an accident can occur, that system of work needs to be corrected.
"However, often what happens is that one or two people make mistakes - either by omitting to do something, by doing something a slightly different way from normal or by doing something extra and unnecessary - which leads to an error and thus an incident/accident," she said. The pilot project examined the root cause of the 40 accidents with a view to helping employees and employers realise "where danger is more likely to lurk".
A central tenet of her research was that "the limited number of ways in which error can occur is bound up with the way we store knowledge, retrieve it and use it to perform tasks". Error tends to happen in a predictable way, with errors in perception, recall and recognition similar to each other. Research into human error explores "consciousness, attention and knowledge structures".
She suggested that there are "three major elements involved in the production of an error": the task being done and the environment in which it is performed; mechanisms governing the performance of the task; and the individual worker.
"Of course, none of the theory amounts to certainty and so, no matter how precise we aim our research to be, generalities will prevail. "We are likely to - if we are lucky - be able to say: `Given this type of task, performed under these types of conditions, this type of person will probably make this type of error'. That's as good as it gets!"
Of the 34 cases eventually used in the research, 82 per cent of the employees involved were less than three years in the job, with 60 per cent less than one year employed.
Only two people had formal "paper and pencil" training about the machine. Most "training" was either on the job training (19 people), watching someone else (16 people) or none (five). In 32 cases, there was no written notice of machine hazards on the machine. In 30 cases, the complete hazards of the machine were not taught. In 15 cases, machine guards were faulty, bypassed, broken or removed.
Some 25 per cent of the injured workers did what they always did but something else was in place that they didn't know about. In half the cases, people did something new or different. Ms Murray defined a slip or lapse as a deviation from the intention (inattention). A mistake is knowledge- or rule-based, where the rule wasn't good enough or the worker didn't know what they needed to know. Incidents can be due to inattention or "where an action goes as planned but it's the wrong plan".
Skill-based errors accounted for 13 injuries. Rule-based errors led to 11. Seven were due to rule/skill errors, while three were due to rule/knowledge deficits.
Ms Murray acknowledged that the research sample was small and that more research was needed. Most accidents involve the application of "bad rules, no rules or last year's rules" or the non-application of good rules.
"How to get the job done safely is not the same as how to get the job done," she said.
Other speakers at the conference included the director-general of the HSA, Mr Tom Walsh; Mr Frank Cunneen, chairman of the HSA; Mr Liam Howe, IOSH Ireland branch chairman; Mr Paul Kelly, health and safety executive, IBEC; Mr Kieran Phelan, health and safety manager, Xerox (Europe) Ireland; Ms Sandra Morgan, health and environment manager of the LUAS light rail project office; Mr Stephen Brady, fire officer with Dublin Fire Brigade; and Mr John Taylor, chairman of IOSH Dublin District.
jmarms@irish-times.ie
