Understanding the Human Factor in Disasters

Abstract

After virtually every major disaster of the last decade there has been a full scale investigation resulting in a lengthy report and a comprehensive list of recommendations. The philosophy of this investigative process, as it is for those incidents with less serious consequences, is that we must learn from experience to prevent future crises from occurring. However, there are barriers to such learning in organisations. This review discusses the different approaches to safety and attempts to show how such 'safety cultures' influence an organisation's attitude to safety management. Three safety cultures are outlined: occupational safety management, risk management and crisis management. Each of these cultures is then linked to a different underlying model of human error causation. This review illustrates how the model of human error causation adopted by an organisation has a profound influence on its choice of remedies for accidents and on its ability to learn from near misses (failures without serious consequences). It is argued that there are major benefits to be gained if an organisation adopts a system induced error perspective on the human error causation. Some of the problems which can occur when an organisation tries to respond to a safety issue are described. These include: overconfidence, an inappropriate emphasis on hardware reliability, a reductionist approach to finding a solution, complacency, and the failure to identify the underlying causes of the accident. A number of major accidents (the Clapham rail crash, the Zeebrugge ferry disaster and the Hillsborough Stadium tragedy) illustrate the key points of the theory.