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Operator Error and System Deficiencies Analysis of 508 Mining Incidents and Accidents
Operator Error and System Deficiencies Analysis of 508 Mining Incidents and Accidents
Operator Error and System Deficiencies Analysis of 508 Mining Incidents and Accidents
Operator error and system deficiencies: Analysis of 508 mining incidents and
accidents from Queensland, Australia using HFACS
Jessica M. Patterson ∗ , Scott A. Shappell
Industrial Engineering Department, Clemson University, 110 Freeman Hall, Clemson, SC 29634, United States
a r t i c l e i n f o a b s t r a c t
Article history: Historically, mining has been viewed as an inherently high-risk industry. Nevertheless, the introduction of
Received 14 September 2009 new technology and a heightened concern for safety has yielded marked reductions in accident and injury
Received in revised form 28 January 2010 rates over the last several decades. In an effort to further reduce these rates, the human factors associated
Accepted 26 February 2010
with incidents/accidents needs to be addressed. A modified version of the Human Factors Analysis and
Classification System was used to analyze incident and accident cases from across the state of Queensland
Keywords:
to identify human factor trends and system deficiencies within mining. An analysis of the data revealed
Accident investigation
that skill-based errors were the most common unsafe act and showed no significant differences across
Human error
Mining
mine types. However, decision errors did vary across mine types. Findings for unsafe acts were consistent
Human Factors Analysis and Classification across the time period examined. By illuminating human causal factors in a systematic fashion, this study
System (HFACS) has provided mine safety professionals the information necessary to reduce mine incidents/accidents
further.
© 2010 Elsevier Ltd. All rights reserved.
0001-4575/$ – see front matter © 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.aap.2010.02.018
1380 J.M. Patterson, S.A. Shappell / Accident Analysis and Prevention 42 (2010) 1379–1385
Fig. 1. Human Factors Analysis and Classification System-Mining Industry (HFACS-MI) framework.
Changes to the second tier included the renaming of ‘crew resource cases obtained represents approximately 10% of the total num-
management’ and ‘personnel readiness’ to ‘communication and ber of incidents and accidents reported to DME during this
coordination’ and ‘fitness for duty’, respectively. At the third tier, time period. The remaining 90% of the reported events did
‘supervision’ was changed to ‘leadership’. This change was made as not require a formal report and therefore were not included.
there are many levels of management that oversee workers, and the The data was obtained from underground and open cut coal
authors did not want users to look only at the operator’s immediate mines, underground and open cut metal/non-metal mines, and
supervisor when investigating this level. No changes were made to quarries.
the fourth tier, ‘organizational influences’. A fifth and final tier of
the HFACS framework was added based on the work of Reinach and 2.2. Coding process
Viale (2006) and was named ‘outside factors’. This level is composed
of two categories: ‘regulatory factors’ and ‘other’ outside factors. In Groups of two human factors specialists coded each inci-
the end, HFACS-MI contained a total of 21 causal categories. A brief dent/accident case. The analysts, five in total, had previous training
description of each causal category within HFACS-MI is provided in and experience classifying incident/accident data with HFACS.
Table 1. Given the high inter-rater reliability found in previous HFACS anal-
yses (e.g., Pape et al., 2001; Wiegmann and Shappell, 2003; Gaur,
2. Method 2005; Reinach and Viale, 2006; Li et al., 2008), consensus classifi-
cation was deemed appropriate for analysis. That is, the group as
2.1. Data a whole discussed each case and classified the identified human
factors within the HFACS-MI framework. The presence or absence
The incident and accident reports used in this analysis were of each HFACS-MI category was evaluated from the narrative,
obtained from the Department of Mines and Energy (DME) in sequence of events, findings, and conclusion. Each HFACS-MI cate-
Queensland, Australia. Information used was gathered from reports gory was counted a maximum of one time per case.
and/or forms submitted by responsible personnel from each mine
on high potential incidents and lost time accidents. A total of 3. Results and discussion
508 cases occurring between January 2004 and June 2008 were
obtained and submitted to further analysis. This was the entire 3.1. Overall results
population of cases for which investigation reports/completed
forms were available. The completed forms were standard for As can be seen in Table 2, the majority of causal factors involved
all mines and across the time period examined. The number of operators and their environment. Not surprising, an unsafe act was
J.M. Patterson, S.A. Shappell / Accident Analysis and Prevention 42 (2010) 1379–1385 1381
Table 1
Brief description of HFACS-MI causal categories.
Outside factors
Regulatory factors: Effect that government regulations and policies have on the operation of the mine. Also includes how actions of the regulator, including inspections
and enforcement, affect health and safety.
Other: The effect society as a whole has on the health and safety of a mine site including economic pressures, environmental concerns, and legal pressure.
Organizational influences
Organizational climate: Prevailing atmosphere/vision within the organization including such things as policies, command structure, and culture.
Operational process: Formal process by which the vision of an organization is carried out including operations, procedures, and oversight among others.
Resource management: How human, monetary, and equipment resources necessary to carry out the vision are managed.
Unsafe leadership
Inadequate leadership: Oversight and management of personnel and resources including training, professional guidance, and operational leadership among other aspects.
Planned inappropriate operations: Management and assignment of work including aspects of risk management, operator pairing, operational tempo, etc.
Failed to correct problems: Those instances when deficiencies among individuals, equipment, training, or other related safety areas are “known” to members of leadership
yet are allowed to continue uncorrected.
Leadership violations: The willful disregard for existing rules, regulations, instructions, or standard operating procedures by management during the course of their duties.
Personnel factors
Communication and coordination: Includes a variety of communication, coordination, and teamwork issues that impact performance.
Fitness for duty: Off-duty activities required to perform optimally on the job such as adhering to rest requirements, alcohol restrictions, and other off-duty mandates.
Unsafe acts
Errors
Decision errors: These “thinking” errors represent conscious, goal-intended behavior that proceeds as designed, yet the plan proves inadequate or inappropriate for the
situation. These errors typically manifest as poorly executed procedures, improper choices, or simply the misinterpretation and/or misuse of relevant information.
Skill-based errors: Highly practiced behavior that occurs with little or no conscious thought. These “doing” errors frequently appear as breakdown in visual scan patterns,
inadvertent activation/deactivation of switches, forgotten intentions, and omitted items in checklists. Even the manner or technique with which one performs a task is
included.
Perceptual errors: These errors arise when sensory input is degraded as is often the case when working underground, in poor weather, around noisy equipment, or in
otherwise sensory impoverished environments.
Violations
Routine violations: Often referred to as “bending the rules” this type of violation tends to be habitual by nature and is often enabled by a system of supervision and
management that tolerates such departures from the rules.
Exceptional violations: Isolated departures from authority, neither typical of the individual nor condoned by management.
identified in nearly all cases. Preconditions for unsafe acts were were then clustered within each category based on underlying sim-
associated with 81.9% of the cases while unsafe leadership was ilarities. For example, “working at heights without fall protection”
identified in 36.6% of the cases. Organizational influences and out- was grouped with other codes involving the misuse or inadequate
side factors were identified in relatively few cases (i.e., 9.6% and use of personal protection equipment. Likewise, “improper isola-
0.0% of cases, respectively). tion of electrical equipment” and the “isolation of the incorrect
Within the category of unsafe acts of operators, the most often equipment” were grouped with other electrical errors. The top
cited error form were skill-based errors followed by decision errors, three examples for skill-based errors and decision errors are pre-
violations and perceptual errors. With regard to the preconditions sented in Table 3.
for unsafe acts, the majority of causal factors involved the physi- As can be seen, the most common type of skill-based errors
cal environment, technical environment and communication and was inadvertent or missed operations. These errors were typi-
coordination. Fewer causal factors were identified at the unsafe cally the result of a breakdown in visual scan or the inadvertent
leadership and organizational influence levels. When causal factors activation of a control. This was not completely unexpected since
were identified at these higher levels, they tended to center around the large amount of activity occurring at a typical mine site can
a single category (e.g., inadequate leadership and organizational often lead to a breakdown in visual scan. Logically, any interven-
process). tion/mitigation strategy should explore ways to reduce operator
reliance on visual detection. Alternatively, one might want to focus
effort on augmenting vigilance, particularly during times when
3.2. Unsafe acts of the operator fatigue and boredom effect performance, like night-time opera-
tions or during repetitive and mundane tasks.
In order to standardize the analysis process, examples were Another common skill-based error was technique errors. An
created for each HFACS-MI category (e.g., inadvertent or missed operator’s technique refers to the way in which they typically com-
operations are an example of skill-based errors). These examples
1382 J.M. Patterson, S.A. Shappell / Accident Analysis and Prevention 42 (2010) 1379–1385
did not appear to have had any long term impact. There was a and (3) experience – with experience comes a better understanding
slight dip in decision errors identified in 2007; however, the his- of one’s decisions. The likelihood that a decision will be successful
torical trend quickly re-established itself at just over 50% of the is markedly reduced if any of these three components are absent
cases. or lacking.
Therefore, it could be that the information available to quarry
3.2.2. Unsafe acts analysis by mine type miners may be suspect or absent. Likewise, the knowledge base
Unsafe acts were examined further by mine type. The percent- of the quarry miners may be less than other mine operations for
age of cases at each mine type that were associated with each a variety of reasons (e.g., poor training practices, more complex
category of unsafe acts is illustrated in Fig. 3. The percentage of tasking, etc.). Finally, it could be that the experience level of quarry
skill-based errors were the most prevalent error form and gen- miners may be less than observed in other mine types.
erally stable across all mine types with the noted exception of Regardless, successful interventions should focus on improving
underground metal/non-metal mines; although the latter was not information access and quality while ensuring that all quarry min-
significant (2 = 4.37, ns). ers are provided sufficient training and knowledge to act safely on
Unlike skill-based errors, decision errors did appear to vary the information. Experience, unfortunately, is something that can
across mine types (2 = 10.39, p < 0.05). For example, underground neither be taught nor substituted for – it merely comes with time.
coal mines had the lowest percentage (23.1%) of cases associated However, depending on the experience level of the quarry work-
with decision errors while quarries yielded the highest percentage force these data suggest that efforts to retain and employ more
(48.0%). The larger question is why decision errors were more fre- experienced quarry miners may be beneficial.
quent at quarries than any other mine types. Decisions are based on In contrast to quarries, underground coal mines exhibit a much
three key elements: (1) information – is the information accurate lower percentage of cases associated with decision errors. This may
and timely; (2) knowledge – does the individual have the requisite be due to the highly structured nature of the tasks coupled with
understanding of the situation and training to make the decision, the reality that most operations are associated with written and
practiced procedures so employees are rarely compelled to cre-
ate their own course of action. Also of note, coal mines tend to
be populated by a more experienced workforce due as evident in
the higher retention rate among coal mines in Australia (MOSHAB,
2002). Obviously, the decrease in turnover naturally leads to work-
ers with a more experienced workforce.
Violations and perceptual errors were identified in relatively
few cases. Differences in perceptual errors and violations across
mine types were not significant, 2 = 7.2 and 3.5, respectively. Due
to the low percentage of cases associated to violations and percep-
tual errors, no meaningful insights could be drawn.
dents and accidents, the specific types of human error had not been We are grateful for the opportunity to carry out this research. We
identified. This study showed that the HFACS-MI framework could would like to thank the mine sites that allowed the author access
be used to systematically identify underlying human factor causes in order to learn more about the mining industry. The recom-
in mining incidents and accidents. More important, these analyses mendations presented in the paper are those of the authors and
provide for the development of data-driven interventions. Since do not represent recommendations from DME or the Queensland
different human error forms require different types of interven- Government.
tions, knowing the most common error forms will enable safety
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