Dealing with Distractions in Safety-critical Operations

Don’t Blink!
Dealing with Distractions in Safety-critical Operations

Keep distractions at bayThe classic example of a distraction leading to a fatal error in a safety-critical situation is the teenage driver who crosses the center line on the road while texting and kills herself or someone else. But driving isn’t the only safety-critical situation, and text messages aren’t the only distractions.

Any task can be subject to distraction-related errors, but some errors will cost more than others—some mistakes are deadly. It’s vital to realize that distractions that would be minor in most circumstances can be major when safety is an issue and equally important to understand that “safety-critical” operations do not necessarily look very dangerous.

3 Seconds from Death

In a study published in the Journal of Experimental Psychology: General in 2013 by Michigan State University researchers, workers were asked to complete a series of tasks on a computer in a specific order and then were distracted for as little as 2.8 seconds by another task assigned by researchers.

Afterward, they often resumed their initial task at a different point in the task sequence without realizing it—inadvertently skipping or redoing steps because their train of thought had been disrupted. A distraction lasting just 2.8 seconds doubled the number of errors the participants committed, while a distraction lasting 4.4 seconds tripled the number of mistakes.

So which types of distractions can cost workers those critical 3 seconds?

Electronic Devices. On May 8, 2009, the operator of the Massachusetts Bay Transportation Authority Green Line train 3612 was texting his girlfriend as he pulled into the Government Center station in Boston. His train crashed into a stopped train without slowing, derailing one car from each train, sending 68 people to the hospital with injuries, and causing nearly $10 million dollars in damage.

Both checking and composing text messages have been implicated in many work-related transportation accidents. Operating a motor vehicle or a piece of heavy equipment is the sort of safety-critical operation most likely to come to mind. It’s not just cell phones that can cause these problems, though. Laptop and notebook computers and tablets are also potentially deadly distractions, even when their use on the job is required.

Interruptions. In October 2009, 64-year-old John Bruce was on a raised belt loader at Al-Mubarak Airbase in Kuwait, handling baggage from a United Airlines 747, when a coworker below moved the belt loader. Bruce fell 12 feet and suffered severe head trauma; he was removed from life support several days later. A lawsuit alleged that the worker who moved the belt loader was distracted at the time because he was chatting with other workers.

Practical TipSomething as simple as a conversation with a coworker can distract an employee at a critical moment. And a safety-critical operation can be something that involves being aware of what your coworkers are doing and how your actions might affect them—as when Bruce’s coworker moved the loader without seeming to realize that Bruce could be harmed by his action.

This is why the lockout/tagout standard, for example, requires training even for workers not directly involved in lockoutltagout operations—because their actions can affect the safety of workers involved in lockout/tagout.

Divided Attention. Patryzjusz Zawadowicz, a 31-year-old Polish sailor, was working two winches as his ship, the 2,600-meter Dublin Viking, was leaving Dublin on August 7, 2008. One of the winches was supposed to be heaving up the stern ramp; the other was veering the stern line.

Zawadowicz, who was the ship’s second officer, had performed the procedure before, but this time, at a critical moment, he made a costly error. Instead of paying out slack, Zawadowicz heaved on the stern line—a mistake likely caused by the need to divide his attention between the two winches.
The stern line was in poor condition, but its deficiencies were missed during inspections. It broke, snapping back and breaking both of Zawadowicz’s legs and dislocating his shoulder. Zawadowicz later died of his injuries.

We like to think we can multitask safely, but the truth, researchers say, is that we’re probably not doing any of those multiple tasks well. If any of the tasks you’re performing has the potential to cause serious injury, divided attention can trigger disaster.
Attention getters

Strategies to Help Workers to Minimize Distractions and Avoid Mistakes

Electronic Devices. Every workplace should have a policy in place to ensure that workers aren’t required to use their cell phones, laptops, or tablets at moments when they should be focused on what they’re doing—like driving.

Interruptions. Landing an airplane is one of the most safety-critical jobs there is, and airlines have gone to great lengths to ensure that pilots are fully focused during landing
procedures. Pilots are trained to work together in teams when landing and are constrained by the “sterile cockpit” rule during landing, takeoff, taxiing, and while flying below 10,000 feet. The rule strictly limits nonessential communication and activities.
To prevent interruptions in any job that can create deadly distractions, make safety-critical procedures an “all-business” team effort.

Divided Attention. This one can be addressed at the planning level. When workers are required to perform safety-critical tasks, don’t give them more than one thing to do at a time. Either give them a stepwise procedure to follow, or give them a single task to do; assigning multiple potentially hazardous tasks is an invitation to disaster. Plan tasks with care, and make sure adequate trained personnel are on hand to perform them.