Human error and risk culture: what sits behind a serious loss?

Consider a maintenance job handed from one shift to the next. The incoming team knows which task is unfinished, but misses a restriction on using the equipment. If the equipment is restarted before it is safe to do so, calling it a communication error would leave an important question unanswered: how did critical information get lost?

“An investigation needs to establish what made the error more likely and whether the safeguards were adequate to prevent it or limit its consequences,” says David Reynolds, Head of Risk Engineering and Surveys at RiskSTOP. “That means examining the information people had, the pressures they faced and the decisions that shaped the work. Those findings should guide what the business changes.”

The Health and Safety Executive (HSE) advises businesses to investigate why human failures happen. It distinguishes unintended errors, such as forgetting a step, from deliberate departures from procedures. Identifying human error should lead to a wider examination of the conditions, systems and organisational factors behind the event. A deliberate departure does not necessarily involve an intention to cause harm; it may reflect an attempt to complete the task despite practical difficulties or competing demands.

For commercial insurance brokers, this offers a useful way into conversations about recurring incidents and weaknesses. Understanding the link between human error and risk culture can help identify where a client needs further risk support.

How leadership shapes risk culture

HSE identifies management commitment and style among the main influences on safety culture, including the tendency to favour production over safety.

Consider a supervisor expected to maintain output while releasing employees for essential checks. If the available time cannot accommodate both, the business should examine the conflict it has created. Simply repeating the instruction to follow procedures leaves that pressure unresolved.

The same applies to how concerns are received. Managers should make it clear how employees can raise difficulties, who can authorise changes and when work needs to stop. Reviewing those arrangements with the people doing the job can expose differences between management expectations and everyday practice.

For brokers, a useful discussion is how the client handles competing priorities when completing a task safely takes longer than planned.

Where information loses its meaning

A task can involve several teams, each holding a different part of the picture. In the opening example, the maintenance team may understand a restriction that the incoming operators have not received. The restriction could concern equipment that other teams depend on, making the handover relevant to both safety and continuity.

HSE’s guidance on communication and shift handovers emphasises sharing the right information at the right time and checking the receiving team’s understanding.

A clear handover should establish the equipment’s current condition, what remains unfinished, any restrictions or isolations in place, and who is responsible for authorising its return to service. Safety-critical information should be communicated verbally and recorded in writing, with the receiving team checking its understanding. Where isolation and locking off are needed to prevent an unsafe restart, a handover does not replace those safeguards.

The cultural question is whether the business provides enough time for that exchange and encourages people to challenge an unclear instruction. A handover form has limited value if completing it becomes the main objective.

When exceptions become the usual method

Procedural drift describes a gradual gap between the agreed way of working and what people actually do. In an illustrative workshop, an extra step might be skipped during a busy period, then omitted again because it appears to add little value.

“An uneventful run of shifts does not establish that a shortcut is safe,” David says. “The important question is why the step exists and what protection is lost when it is removed.”

HSE advises involving users in procedure design and walking through tasks with them. Risk professionals can use that approach to understand whether instructions reflect the equipment, staffing and conditions on site.

Employees who identify a mismatch should have a clear route to report it and get an answer before an informal solution takes hold.

Any proposed change should be assessed and authorised before implementation, with affected employees and contractors informed. Where an essential control cannot be maintained, the task should be paused until safe arrangements are established.

Brokers can ask how the client investigates recurring workarounds, reviews possible changes and checks that revised arrangements remain effective.

What Buncefield demonstrates

At Buncefield in 2005, explosions and fires caused damage and disruption beyond the depot. HSE’s review identified weaknesses in safety management and oversight, alongside failures in the safeguards intended to prevent an overflow.

Buncefield was a major hazard installation. For other businesses, the useful lesson is to ask how management knows that critical controls are working and how concerns about them are acted on.

Turning understanding into action

“Start with a task where a failure could cause serious injury, property damage or business interruption,” David suggests. “Talk to the people doing it and compare the procedure with what happens in practice.” Include those supervising the task and ask what makes the agreed method difficult to follow.

A competent review should consider whether redesigning the task or equipment could reduce the likelihood or consequences of error. It should also consider improvements to communication, staffing, competence and supervision. The response should address the conditions identified and reduce dependence on people remembering every step correctly.

Keep the discussion connected to the client’s main exposures: harm to people, damage to property and disruption to trading. Explore which activities or equipment could turn a local mistake into a wider operational problem.

Repeated control failures, uncertainty about a safeguard or unresolved differences between procedures and actual work are reasons to discuss specialist risk input with the client. Clear ownership and follow-through matter. The business should record what it intends to change and check whether the action has addressed the original difficulty.

The next conversation could start with a recent incident, near miss or workaround. Establish what the business learnt about the circumstances behind it, and what has changed as a result.