Ever pressed the brake instead of the accelerator?

You know how to do the task. You’ve done it a thousand times. You train others in how to do it. So, why today did you make a mistake that led to an injury? In a split second you did something that you don’t usually do. You know what you are doing. You are well trained and experienced.

I’m always in my kitchen baking. A few months back, I decided to make a banana cake and a sponge cake. Those of you that are bakers will know that a banana loaf takes longer to cook than a sponge. So I did what I always do. I set to work making the banana cake and got it in the oven to cook. I then made the sponge batter and got it ready for the oven. I opened the door. I needed to move the banana loaf to fit the sponge tin in. So I put my hands on the tin and I moved it……..

After a number of expletives, a lot of cold water and a trip to minor injuries, I spent a week with two heavily bandaged, painful fingers. Two fingers on which I’m not convinced I’ll see a fingerprint for a while! After years of baking, what possessed me to move that tin without my oven gloves, my PPE? I made a skills -based error, a mistake during a familiar, routine task in which I have experience. Did you ever go to press the accelerator and press the brake instead? It’s the same thing.

We are all human and mistakes will happen, but it is something that employers should consider in their risk controls. What damage can pressing a wrong button, or reading a wrong gauge do? Well, if that button releases the wrong substance into the wrong container, then the results could be catastrophic. Training and experience, whilst very necessary, won’t always remove human failure. Looking at the design of tasks and building error tolerant systems can help, as well as considering work routines, motivation and morale. Perhaps if my oven gloves had been hanging right next to the oven, I would have remembered to put them on!

For more information on managing human error, the HSE guidance can be found here –

https://www.hse.gov.uk/humanfactors/topics/humanfail.htm

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