Incident investigation workplace design

It is illogical to conclude in an incident investigation that the principal causal factor is the unsafe act of the worker if the design of the workplace or the work methods is error-provocative. In such cases, the error-provocative aspects of the work should be considered primary. (A few organizations are giving courses on Preventing Human Error which focus on how to identify and prevent what they are calling error-likely work situations. This is a recent development.)... 

For instance, incident investigation methods should direct inquiry very early on into what may have been programmed into work systems through the design of the workplace or work methods. They should promote inquiry that determines whether the design of the work is error-conducive. For all injuries, the first question should be. Are there workplace design or work methods design implications ... 

It is illogical to conclude in an incident investigation that the principal causal factor is the worker s unsafe act if the design of the workplace or the work methods is error inviting. In such cases, the... 

Fatality reports, only, were received from the federal government entity. Their thoroughness was commendable. Seldom do comments in incident investigation reports relate to the inadequacy of policies set at an upper management level, or of the appropriateness of standards and procedures, or decisions made affecting the design of the workplace and work methods. These reports did so.Tliey prove that it can be done. 

For how many incidents have the decisions affecting the sociotechni-cal workplace and work methods resulted in situations that are conducive to operator errors In Chapter 14, Incident Investigation Studies of Quality, it was said that in a substantial number of the investigation reports collected by this author, entries suggested that further inquiry should have been made into the design of the workplace or work methods. In many cases, the investigation reports pertained to incidents that occurred in error-provocative situations. Yet, often in those instances, only unsafe acts of employees would be recorded as the incident causal factors. 

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