What is HSG48?
HSG48, "Reducing Error and Influencing Behaviour," is a foundational guidance document from the Health and Safety Executive that addresses the critical role of human factors in workplace safety. This comprehensive publication provides a framework for understanding why people make errors and how organisations can design work systems, procedures, and environments that reduce the likelihood of human error causing harm.
Human factors (sometimes called ergonomics or human engineering) examines how people interact with their work environment, equipment, and procedures. HSG48 makes the important point that human error is rarely the root cause of accidents; rather, errors typically result from systemic failures in how work is organised, designed, and managed. By understanding the factors that influence human performance, organisations can move from a blame culture towards genuine safety improvement.
The guidance draws on decades of research into human cognition, behaviour, and organisational psychology to provide practical advice applicable across all industries. It recognises that humans are fallible and that well-designed work systems must anticipate and accommodate human limitations rather than assuming perfect performance.
Who Needs This Document?
HSG48 is valuable for anyone seeking to improve workplace safety through better understanding of human behaviour:
Primary Audiences:
- Health and safety professionals and managers
- Operations managers and supervisors
- Safety culture and behavioural safety specialists
- Incident investigators and analysts
- Training and competence managers
Secondary Audiences:
- Senior management responsible for safety strategy
- HR professionals involved in selection and training
- Engineers and designers of work systems and procedures
- Quality managers (given the overlap between safety and quality issues)
- Organisational development professionals
The principles in HSG48 apply across all sectors, though they are particularly valuable in high-hazard industries where human error can have catastrophic consequences.
Key Topics Covered
HSG48 provides comprehensive coverage of human factors principles and their practical application:
Understanding Human Error
The guidance explains different types of human error:
- Slips and lapses: Unintended actions where the intention was correct but execution failed (forgetting a step, pressing the wrong button)
- Mistakes: Intended actions based on incorrect decisions or flawed understanding
- Violations: Deliberate departures from procedures, rules, or instructions
Understanding these distinctions helps organisations develop appropriate prevention strategies.
Factors Influencing Human Performance
HSG48 examines the multiple factors that affect how well people perform:
Individual Factors:
- Competence, skills, and experience
- Physical and mental capabilities
- Personality and attitude
- Current physical state (fatigue, illness, stress)
Job Factors:
- Task design and complexity
- Workload and time pressure
- Working environment (noise, lighting, temperature)
- Equipment design and interface
- Procedures and their usability
Organisational Factors:
- Safety culture and leadership
- Communication systems
- Supervision and monitoring
- Resources and staffing levels
- Management of change
Designing for Human Capabilities
The guidance provides advice on designing work to match human capabilities:
- Simplifying tasks and reducing complexity
- Designing intuitive equipment interfaces
- Creating usable procedures and checklists
- Managing workload and preventing fatigue
- Building in error-detection and error-recovery mechanisms
Procedures and Their Limitations
HSG48 addresses why procedures often fail to prevent errors:
- Procedures that are impractical or impossible to follow
- Excessive numbers of procedures
- Poorly written or unclear instructions
- Lack of worker involvement in procedure development
- Failure to update procedures when conditions change
Training and Competence
The guidance covers effective approaches to training:
- Assessing training needs based on task analysis
- Designing training that addresses likely errors
- Refresher training and competence maintenance
- Training for abnormal and emergency situations
- Verification of competence in practice
Behavioural Safety Approaches
HSG48 examines behavioural safety programmes:
- Observation and feedback systems
- Antecedent-Behaviour-Consequence (ABC) model
- Positive reinforcement approaches
- Limitations and potential pitfalls of behavioural programmes
- Integration with broader safety management
Safety Culture
The guidance addresses organisational culture factors:
- Leadership commitment and visibility
- Trust and openness in reporting
- Learning from incidents and near misses
- Just culture principles
- Continuous improvement approaches
Using This Guidance
Applying HSG48 principles requires a systematic approach:
Step 1: Assess Current Understanding Review how human factors are currently considered in your organisation. Examine whether incident investigations look beyond immediate human error to underlying causes.
Step 2: Analyse Tasks and Risks For high-risk activities, conduct task analyses that identify where human error could occur and what factors might contribute to errors. Consider all individual, job, and organisational factors.
Step 3: Review System Design Examine whether work systems, equipment, and procedures are designed to match human capabilities. Identify opportunities to simplify tasks, improve interfaces, and build in error defences.
Step 4: Strengthen Organisational Factors Address the organisational conditions that influence behaviour:
- Demonstrate visible leadership commitment
- Ensure adequate resources and staffing
- Foster open communication about safety concerns
- Implement just and fair responses to incidents
Step 5: Monitor and Learn Establish systems to monitor human performance issues:
- Near-miss reporting systems
- Observation programmes
- Regular review of procedures and working conditions
- Learning from incidents across the organisation and industry
Why It Matters
Understanding and applying human factors principles is essential for several reasons:
Root Cause Analysis: Many incidents are superficially attributed to "human error" without examining why the error occurred. HSG48 provides frameworks for moving beyond blame to identify genuine root causes that can be addressed.
Effective Prevention: Interventions targeting only individual behaviour (discipline, retraining) are often ineffective because they fail to address systemic factors. Understanding human factors enables more effective prevention strategies.
Legal Requirements: The Management of Health and Safety at Work Regulations require employers to assess risks including human factors. HSE expects organisations to consider human factors in their safety management.
Major Hazard Industries: In sectors like nuclear, petrochemical, and aviation, human factors are recognised as critical to preventing catastrophic events. The principles in HSG48 derive substantially from these high-reliability industries.
Safety Culture: Organisations with strong safety cultures understand human factors and avoid simplistic blame responses. HSG48 supports the development of learning cultures that continuously improve.
Cost-Effectiveness: Addressing human factors often involves relatively low-cost interventions (procedure improvements, better communication, workload management) that can significantly reduce incidents.
By applying the comprehensive guidance in HSG48, organisations can create work systems that recognise human limitations and enable people to work safely, even when errors occur.