Thursday, 3 January 2013

Human Factors – the key to safer practice

Pick up any book or training manual on what are variously referred to as ‘human factors’, ‘non-technical skills’ or ‘crew resource management’ [1] and you will see reference to a set of skills that are important for the safe performance of tasks in any safety critical industry.

For example a recent textbook [2] lists the following seven areas:

  • Situational awareness / being aware of the work environment
  • Making decisions
  • Communication
  • Teamwork
  • Leadership
  • Managing stress
  • Coping with fatigue

Human factors training, now mandatory in all western airlines and increasingly used in medicine and a variety of transport and engineering industries, concentrates on increasing employees’ skills in these areas.

The assumption is that we are all prone to error. We work in organisations and environments that have imperfect defences against human error [3]. The human being - the employee, the professional - is the last defence against what may turn out to be a catastrophic failure. So it follows that the employee must be best equipped to detect, avoid and mitigate errors as they arise in the workplace.

Learning some simple, non-technical skills to address each of the seven areas is not difficult. For example being aware of the possibility of confirmation bias [4] (a natural tendency to select evidence that confirms what we already believe to be the truth) helps decision-makers review the evidence again more critically.

Being better equipped to communicate more clearly and assertively, and to listen more attentively, especially to junior colleagues, can help avoid the kind of misunderstandings that contributed to the Tenerife (Los Rodeos) and Kegworth air disasters [5] [6].

And understanding the impact of stress and fatigue helps us avoid overloading colleagues, and indeed ourselves, to the point where our ability to make sound decisions is impaired.

The relevance of all this to child protection seems to me self-evident. Children like Maria Colwell, Jasmine Beckford, Tyra Henry, Victoria Climbié, Peter Connelly and Khyra Ishaq died NOT because those responsible for their care were professionally incompetent or negligent. Rather the failures stemmed from skills deficits that might have been rectified had those concerned studied and trained in human factors.

Child protection must be no exception. If human factors training is good enough for other safety critical sectors, such as airline pilots and surgeons, child protection professionals must also embrace this way of thinking. The result will be safer practice and safer children.     

Want to find out more? Look at:


[1] Wiener, E. Kanki, B and Helmreich, R. (1993) (eds.) Cockpit Resource Management. SanDiego: Academic Press

[2] Flin, R. O’Connor, P and Crichton, M. (2008) Safety at the Sharp End: a guide to non-technical skills. Farnham: Ashgate.

[3] Reason, J. (1997) Managing the Risks of Organisational Accidents. Aldershot: Ashgate.

[4] Wason, Peter C. (1960), "On the failure to eliminate hypotheses in a conceptual task", Quarterly Journal of Experimental Psychology (Psychology Press) 12 (3): 129–140, doi:10.1080/17470216008416717, ISSN 1747-0226

[5] Weick, K (1991) “The vulnerable system: an analysis of the Tenerife air disater.” Journal of Management 16, pp 571-593

[6] AAIB (1990) Report on the Accident to Boeing 737-400 G-OBME near Kegworth, Leicestershire on 8th January 1989.  Air Accident Report 4/90. London: HMSO