Brownfields 2013
Ron Snyder, HMTRI/CCCHST
Adapted from:
Todd Conklin PhD
Los Alamos National Laboratory
Never Take a
Sleeping Pill and a
Laxative at the
Same Time.
Never Remove A
Safety Barrier That
Has A Dent In It.
The Fastest Way
To Improve Safety
In Your Organization…
Change the Way Your
Organization
Responds to Failure.
Safety is not the
absence of
accidents.
Safety is the
presence of
defenses.
Safety is the ability to
perform work in a
varying and unpredictable
work environment.
Start
Of
Job
Mission
Success
Work as Planned
*Here’s what we know…
*Planned work is normally more
successful than unplanned work
*All plans are great until we begin to use
them
*Planning assumes perfection – perfection
is a terrible operational performance
standard
*
P
Or Are They..
“ To understand failure…we must first
understand our reaction to failure.”
“People do not operate in a vacuum,
where they can decide and act allpowerfully. To err or not to err is not a
choice. Instead, people’s work is subject
to and constrained by multiple factors.”
— Sidney Dekker
*
Things that never
happened before…
Happen all the time.
Karl Weick
Worker’s Don’t Cause
Failures.
Worker’s Trigger Latent
Conditions That Lie
Dormant In Organizations
Waiting for This Specific
Moment In Time.
“Accidents are the
unexpected combination
of normal performance
variability”
Eric Hollnagel
*
Accidents Happen Because:
*What is about to happen is simply not
possible.
*What is about to happen has no perceived
connection to what is currently happening.
*The possibility of getting the intended
outcome is well worth whatever risk there is.
*
Start
Of
Job
Mission
Success
Work as Done
Your Workers
Are Masters of
Complex Adaptive
Behavior…
Clearly Safe
to do Work
The Grey Area:
Uncertain
interpretation
of Safe work
Clearly Not Safe
to do Work
Unclassified
*
19
Human
Error
Expertise
Identification
Exercise
How many times does the uppercase
or lowercase letter“F”appear in
the following sentence?
Finished
Finished files
files are
are the
the reresult of years of scientific
study combined with the
experience of many years.
years.
21
“Mistakes arise directly from the
way the mind handles
information, not through
stupidity or carelessness.”
-Edward de Bono PhD
*
Events aren’t
predictable,
But the environment
in which Events are
most likely to happen
is…
1.
2.
3.
4.
5.
6.
Choose and number between 1 and 10
7.
With the last letter of this country – choose an
animal
8.
With the last letter of this animal – choose a
fruit
Multiply that number by 9
Add the two digits of this number together
Subtract 5 from this new number
Translate this number to a letter – 1 = A, 2 = B…
With this letter – choose a country that starts
with that selected letter
Denmark
Kangaroo
Orange
“The problem with
the future is that
more bad things
can happen than
will happen.”
Start
Of
Job
Event
Hazard
Accumulation of Risk
*Where will the next safety event be
in your organization?
*What can we do today to prevent
this event.
*
The human
performance in
question usually
involves a set of
interacting people.
“Risk that you can control are
much less a source of outrage
than risks you can NOT control.”
-Peter Sandman, PhD
*
*Western-Economic View
*Bias View
*Cultural View
*All Represent an interactive
phenomenon
*
The context in
which events
happen plays a
major role in human
performance.
* Human error is a cause of
* Human error is a symptom of
* To explain failure,
* To explain failure, do not try to
* These investigations must
* Instead, find out how peoples’
accidents
investigations must seek
failures of parts of systems
find inaccurate assessments
and bad decisions
*
trouble deeper inside a system
find out where people went
wrong
actions and assessments made
sense at the time given the
circumstances that surrounded
them.
* Complex systems have a strong tendency to move
incrementally toward unsafe operations
* Human errors become more complex when systems become
more complex
* With increased complexity, more unanticipated situations
exist
* More encounters in which procedures are non-optimal or nonworkable
*
37
Unclassified
* Human errors become more complex
* More unanticipated situations exist
* More encounters in which procedures are not optimal
(work-arounds) or non-workable situations
*
38
Unclassified
Achieve success
or
Avoid failure
*
39
Unclassified
In highly complex processes – there will be more errors
(because of the complexity of the process) – However, highly
complex processes have much less tolerance for error.
*
40
Unclassified
Workplaces and organizations are easier to manage
than the minds of individual workers. You cannot
change the human condition, but you can change the
conditions under which people work.
— Dr. James Reason
*
41
Unclassified
Event Prevention
Happens Through
Learning.
Start
Of
Job
Risk
Understanding:
Learning
Normal
Work
Event
Hazard
Accumulation of Risk
The attribution of
error-after-the-fact is
a process of social
judgment rather than
an objective
conclusion.
When investigating a
Failure - Organizations
ultimately “dumb” all
worker decisions down
to two choices:
1. To Screw Up
2. To Not Screw Up
Deviation from
Expected
Behavior
Error
Violation
The Gray Area
Potential
Learning
Target
Area
*
“Intentional Variation”
1.
2.
3.
4.
5.
6.
7.
8.
Are the people ok?
Is the facility safe and stable?
Tell me the story of what happened?
What could have happened?
What factors led up to this event?
What worked well? What failed?
Where else could this problem happen?
What else should I know?
*
1. Constantly fixate on the next failure.
2. Work hard to reduce operational
complexity.
3. Respond seriously to pre-cursor
information.
4. Respond deliberately to actual events.
*
Safety is not the
absence of
accidents.
Safety is the
presence of
defenses.