Understanding Human Factors in Workplace Safety: A Comprehensive Approach
In the realm of keselamatan tempat kerja and health (WSH), the term “human error” often surfaces as a quick conclusion in incident investigations. However, for safety professionals operating in high-risk environments, this perspective is overly simplistic. Incidents are rarely the result of a single individual’s negligence; instead, they stem from complex interactions among humans, technology, work environments, and organizational decisions. This is where the concept of human factors becomes pivotal.
The Importance of Human Factors
Human factors in WSH examine how system design, workload, communication, culture, and organizational policies influence human performance. This perspective has evolved from theories like those presented in James Reason’s “The Human Contribution,” which emphasizes that humans are not merely sources of failure but also vital components of system resilience. In essence, while humans can make mistakes, they also play a crucial role in preventing failures through adaptation.
Distinguishing Between Error, Violation, and Drift
In practical investigations, distinguishing between three key concepts error, violation, and drift is foundational for accurate analysis. An error is an unintentional action that deviates from a plan or objective. Errors can manifest as slips (execution mistakes due to distraction), lapses (forgetfulness), or mistakes (judgment errors due to incorrect knowledge or mental models). For instance, an operator might misread a chemical label due to similar design features, or a technician may misinterpret operational parameters due to ambiguous procedures. Interventions for errors typically involve systemic changes such as design improvements, procedure simplification, enhanced training, or control engineering.
On the other hand, a violation involves a conscious deviation from rules or procedures, though it is not always indicative of malicious intent. Violations can be categorized into routine violations, which become normalized within teams; situational violations, which arise under time pressure or resource constraints; and exceptional violations, which occur in emergencies. For example, bypassing an interlock to meet production targets exemplifies a violation. Analyzing violations necessitates critical questions: Are the rules realistic? Is there a conflict between production targets and safety?
Drift into failure describes a gradual shift from safe practices to risky behaviors that ultimately become normalized. Popularized by Sidney Dekker’s work, this concept illustrates that drift does not occur suddenly; it results from small, initially rational compromises in the context of cost, time, or productivity pressures. Over time, operational standards on paper diverge from actual practices in the field. Understanding these distinctions is crucial as they inform control strategies. Errors require more robust system designs, violations necessitate contextual and motivational evaluations, and drift calls for reflection on organizational governance and performance indicators that may encourage risky behavior.
Blame-Free Investigations: From Individuals to Systems
Modern investigative approaches stem from the assumption of local rationality: at the moment, the actions of individuals make sense based on the information and pressures they face. This principle aligns with the Safety-II approach developed by Erik Hollnagel, which emphasizes understanding how systems typically succeed rather than solely focusing on failures. A blame-free investigation does not imply a lack of accountability; rather, it avoids oversimplifying issues to mere “individual errors” without examining systemic contexts.
Investigative questions should focus on conditions rather than judgments. Examples of human factors-based interview questions include: What indicators did you use to assess safety at that moment? What pressures or targets influenced your decision? Were the procedures and resources adequate? Has this practice become a team norm? Since when? How did the organization respond to similar incidents in the past? These questions open avenues to understand operational realities that often diverge from formal documentation.
Mapping Organizational Factors
To avoid a narrow focus on frontline workers, investigations must map the contributions of organizational factors in layers. The first layer includes direct actions at the incident site. The second layer encompasses local working conditions such as workload, equipment design, shift schedules, and supervisory quality. The third layer involves managerial processes: management of change (MOC), permit systems, training, and audit. The fourth layer touches on strategic policies like production targets, incentive systems, and budget allocations. The fifth layer considers external contexts: market pressures, client demands, and regulations.
This layered approach aligns with the system management principles outlined in ISO 45001, which emphasizes leadership and organizational context as integral components of WSH systems. For instance, aggressive production targets may lead to delays in preventive maintenance, increasing the frequency of disturbance alarms. Operators may then become desensitized to alarms deemed “nuisance.” When critical alarms arise, risk sensitivity diminishes, leading to incidents. In this scenario, focusing solely on the operator obscures deeper-rooted issues.
Moving Towards a Learning Culture
Distinguishing between error, violation, and drift is not merely a terminological classification but a framework for determining appropriate interventions. Thorough investigations do not stop at identifying who acted but delve into why those actions made sense within the existing system. As organizations transition from a blame culture to a learning culture, the quality of risk control fundamentally improves.
Human factors are not a defense for mistakes; rather, they provide a lens to view the complexities of systems holistically. This is where true learning in WSH begins. By integrating tools like PEER,, organizations can enhance their compliance with health and safety regulations, streamline personnel management, and improve workflow efficiency across various modules. Whether in konstruksi, oil and gas, or manufacturing, understanding human factors through the lens of PEER can lead to safer, more resilient workplaces.
