The Hindu reported that a crane accident was caused by human error.
The V. Somasundaram, chief general manager (construction) from Chennai Metro Light Rail, said:
“The operator mishandled the crane. Usually, the crane is perpendicular to the object it is lifting, but the operator positioned it at an angle of 30 degrees from the object.”
Here’s another quote from the article:
“According to sources with the contractor, crane operator Amalesh Yadav from Bihar is a 22-year-old with over a year’s experience in operating cranes. Police are looking for Amalesh, who has been absconding since the accident.”
Human error as a “cause” or is it a Causal factor that needs to be investigated further?
What do you think???
Category: Accidents, Current Events, Investigations
17 Comments »
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Clearly (well, in my mind anyway) the investigation needs to go further. Why did poor ol’ Amalesh do what he did? What was behind his decision to lift at that angle?
The approach of this company is reprehensible and unfortunately not that uncommon. No wonder Amalesh took off.
It is my heart felt belief that most people will set about their work with the right intention – to do as good a job as they can. Investigators need to seek to understand why certain decisions were made. This will lead to unearthing of sytemic problems such as training, procedures, resource issues, maybe even cultural and business drivers.
Secondly – how effective is any investigation going to be with a culture that looks to blame? Imagine yourself having to conduct interviews. Interviewees will clam up for fear of reprisal and the organisation will never uncover the real root causes of any incident.
One of the reasons I dislike the expression “Pilot Error”.
Human error is NOT a cause. Go deeper.
Comment by Graham Elliott — August 20, 2012 @ 10:03 pm
“Human Error” is NOT a Root Cause and requires to be investigated further. While the “peril” (cause of loss), may be “human error”, the direct cause is usually “hazardous thoughts and acts”, which if proved further would lead to the indirect cause of “hazardous conditions and systems”, which when probed further would invariably lead to the root cause of “hazardous culture – comprising of hazardous managment practices and lack of safety leadership.
Most investigations stop at “human error” which is convenient way of those in authority relenquishing their responsiblilty. The net result is fire the person who committed the “human error”, and contiue to live in denial that most problems are caused due to “huiman error” until the next accident and once again call it “human error”. Perhaps this is HUMAN ERROR too!!!!
Mark Twain has been quoted as saying that “Human error is an act of God, since God created man on the seventh day when He (God) was fatigued and so created man imperfect”. So is human error a DIVINE ERROR? :-)
Comment by A.W.J. (Tony) Fernandez — August 20, 2012 @ 10:18 pm
I love the idea that the reason that God created man imperfect was that God was fatigued.
After all, creating the universe is a big job!
Comment by Mark Paradies — August 20, 2012 @ 11:32 pm
To quote Trevor Kletz in a paper last year for the Safety & Reliability Society (SaRS Journal Vol 31 Issue 1)
Human error is not a cause. “There are a lot of books and papers on human error but the adjective is unnecessary. All errors are human errors.”
The real point is whether in the procedures, the design, the organisation, other people issues, or a combination of these. and the investigation needs to tease this out.
Comment by Pete Stanton — August 21, 2012 @ 2:48 am
I follow the quote of Mr Kletz referred to in the comment by Mr Stanton: all errors are human. After all, if it was not for humans, the crane in the article would simply not exist, nature does not produce cranes. So the question in itself is futile. Even the concept Root Cause seems futile, if you dig deep enough you will conclude that all problems were caused by the Big Bang. The more interesting question is: ” what can we do to prevent this in the future and for all similar cases.” If we are satisfied with finding a guilty party, this question will not be asked and the accident will repeat itself over and over again.
Comment by Vandenbrande Willy — August 21, 2012 @ 3:06 am
Human error is a causal factor which need to be investigated. Have to find the root cause which lead to Human error.
Comment by John A.Simba — August 21, 2012 @ 9:20 am
A root cause that we look for must be one that fundamentally provoked the action/led to the problem AND is something that can be controlled in the future (within the control of management to address). Therefore, unless you intend to not hire humans, human error is not an appropriate root cause that we would allow to stand in a root cause evaluation report. We simply can not address this so the identification of this as a cause allows no meaningful preventive corrective action. This is the same concept as blaming a tornado for damage to your plant because it caused a loss of power at the plant. The root cause was the tornado – or an act of GOD – but this can not be addressed with a corrective action short of building a tornado-proof dome over all structures. A better root cause for the damage to the plant in this case would be the less than adequate defense in depth design allowing the loss of power to cause plant damage. This cause is actionable with a design change. Similarly, if we find out what provoked or allowed the human error to result in the undesired consequences, then we have a real chance of implementing a corrective action to prevent recurrence
Comment by Mark H — August 21, 2012 @ 9:24 am
Life should be black and white but unfortunately it is grey. Human Error is misused as a root cause – YES, an underlying reason (true root cause) is often determinable i.e. training, adherence to process, unclear or incomplete requirements or test, physical or emotional influences (fatigue, drugs, drink, food, medical…) etc. People tend to stop at “human error” incorrectly. BUT sometimes after investigation, this is where you have to stop – when you have a person who is well trained, using clear and correct procedures, has a clean record (has no systemic issues), under no determinable physical or emotional influences—what you are left with is “bad hair day (BHD)” or “brain fart (BF)”. My solution AND question would be – o.k., lets not use “human error” as a root cause (see everyones comment on why not) BUT what do we call the root cause when we determine that a human caused an error with no discernable reason? I hate “undeterminable” (this is an audit finding generator and has often been used as a crutch for poor RCAs, like human error) so I vote for Bad Hair Day (as BF is not considered polite in all circles).
Comment by Emile Captain — August 21, 2012 @ 9:54 am
Human error is never a root cause in my mind nor has it ever been. Something caused the human act that caused the accident, the decision was made by the human but the cause for the decision to be made needs to be documented and investigated. Additionally, I may be on a lonely island here, but the idea that there is ONE and only ONE root cause is absolutely wrong.
Comment by Keith A. Richmond — August 21, 2012 @ 9:55 am
God created man on the sixth day and rested on the seventh. The real problem came at the fall – man fell on his head and the rest is history!
Agreed. Human error is a causal factor. There are reasons humans err. Things like a snake in the grass.
Comment by Michael Rodriguez — August 21, 2012 @ 2:51 pm
Thanks Mike … Keep us straight!
Comment by Mark Paradies — August 21, 2012 @ 3:26 pm
I frequently read but seldom contribute. But here I must. Human error occurred, but there remains a root cause yet to discover / identify. Somewhat over-simplified, the question might be, “What caused the (system / process) failure”?, rather than Who caused the failure?.” One would be prudent to search for the culprit, yet lurking on a branch of the Root Cause Tree!
Comment by Julian — August 21, 2012 @ 5:58 pm
I agree with most of the comments, but not beeing that experienced in Root Cause Analysis, I would like to know if human error can be a root cause at all.
I think the quoted example first of all is an example of a badly conducted RCA which could be caused by an authoritarian management culture. (This could also explain why Amalesh decided to run away).
If the analysis had been deeper – e.g. – Amalesh might have received an order from a senior person on the ground (could have been his boss?) to do what he did. The order could even have been emphazised by threats. This is a “catch 22” situation for Amalesh, do what you are told even you know it is hazardous, or get fired. But isn’t it a human error if he choose to do the hazardous thing? There are a lot of causal factors, but in the end I think it is a human error?
Another example could be that Amalesh for a long time has been complaining over the disregarding of safety precautions on his job. Management has listened but done nothing. The cup is full for Amalesh and he has decided to take things in his own hand. Is that a human error? Probably a crime – but still? I leave the question open but I would like to read som answers with arguments.
Finally I would like to join the quoting chorus and quote Cicero: “errare humanum est” – but add that it is still an error.
Comment by Jan Waehrens — August 22, 2012 @ 3:02 am
If you are calling the root cause human error, then you are not asking “why” enough times.
There are a lot of factors that can result in the error:
Training, system design, data format, distractions, cognitive overload, rationalized decision making, just to name a few
Without understanding the entire big picture surrounding the event, you can’t correctly identify the causes that led to the error, nor can you implement effective actions to prevent the next one.
Comment by Tim S, — August 22, 2012 @ 5:18 am
Human Error is neither a root cause nor a causal factor. It is at best, a category of causes and factors as it lacks specificity. A causal factor, by definition, is a mistake or failure. It would appear from the article that one of the possible causal factors to this accident was that the crane operator tensioned the lifting cable when the crane was not directly over the load. The root causes of this causal factor would have to be analyzed. See sections 1.1 and 3.7 of the TapRoot(R) text for full definitions.
The reason the workers were in the pit (therefore in the line of fire) while the load was being lowered needs to be investigated as well. Prayers go out for the workers and their families; this tragic theme of human proportions is repeated entirely too often.
Comment by Christopher W — August 22, 2012 @ 4:24 pm
To eliminate human error, all you have to do is ask “why” one more time: Why did the human err? This is not to say that humans are infallible, we can and do err but the question is why did we do so. A process may have lacked adequate safeguards, we may have had incorrect information and, arguably, all errors are ultimately human errors but at some point the causal chain has to stop – without invoking the supernatural, there is no true root cause of anything. Stopping the causal chain at the human is generally laziness or unwillingness to take the next step and find the true cause. It’s much easier to claim retraining the human, firing the human, punishing the human or some other action taken to correct the human solved the problem.
Comment by Stephen Stanley — August 29, 2012 @ 2:16 pm
Human error is never a cause so our motive should never to look at What of the incident but rather Why and How of the incident should be interrogated .Both these terms deal with Psychological.ergonomical and other aspect of factors contributed in human error.
Comment by Kushi — January 31, 2013 @ 9:44 am