The
Curious
Organization
Todd Conklin PhD
Royce Railey
Sr. Safety Advisor
Regional S&H Manager
Los Alamos National Labs
Cintas Corporation
toddconklin@gmail.com
Never take a sleeping pill
And a laxative
At the same time…
…In any order
The
Curious
Organization
Conklin/Railey
Safety is not the
absence of
Accidents.
Safety is the
presence of
defenses.
The
Curious
Organization
Conklin/Railey
P
The
Curious
Organization
Conklin/Railey
“ To understand
failure…we must first
understand our reaction
to failure.”
— Sidney Dekker
*
The
Curious
Organization
Conklin/Railey
Workers Don’t
Failures.
Cause
Worker’s Trigger Latent
Conditions That Lie
Dormant In Organizations
Waiting for This Specific
Moment In Time.
Conklin/Railey
Ask
How
Not
The
Curious
Organization
Why!
Conklin/Railey
We Must Manage
Worker Behavior and
Work Processes
In Parallel…
*
The
Curious
Organization
Conklin/Railey
1. People are fallible
2. Error-likely situations are predictable
3. Individual behaviors are influenced
4. Operational upsets can be avoided
5. Management’s response to failure matters
*
The
Curious
9
Organization
Conklin/Railey
Human Performance Principle 1:
*
Conklin/Railey
Human
Error
Expertise
Identification
Exercise
The
Curious
Organization
Conklin/Railey
How many times does the
uppercase or lowercase
letter“F”appear in the
following sentence?
Finished files are the result of years of scientific
study combined with the
experience of many years
years..
The
Curious
Organization
12
Conklin/Railey
“Mistakes arise directly from the
way the mind handles
information, not through
stupidity or carelessness.”
-Edward de Bono PhD
*
The
Curious
Organization
Conklin/Railey
Error
is not a choice.
Mistakes
=
Violations
The
Curious
Organization
Conklin/Railey
Workers
Are Masters of
Complex Adaptive
Behavior…
Conklin/Railey
The
Curious
Organization
Clearly Safe
to do Work
The Gray Area:
Uncertain
interpretation
of Safe work
Clearly Not Safe
to do Work
Unclassified
16
*
The
Curious
Organization
Conklin/Railey
Clearly Safe
to do Work
Event
Clearly Not Safe
to do Work
Unclassified
17
*
The
Curious
Organization
Conklin/Railey
Accidents happen
when workers find
themselves in
situations where it is
easy to get hurt and
hard to be safe.
The
Curious
Organization
Conklin/Railey
Human Performance Principle 2:
*
The
Curious
Organization
Conklin/Railey
Events aren’t
predictable,
But the environment
in which
Events may happen
is…
The
Curious
Organization
Conklin/Railey
Where will the
next safety event
happen at your site?
*
Conklin/Railey
Collectively
tell
the
STORY
The story of
of where the
all the little
next event
events….
may happen.
Conklin/Railey
Conklin
Human Performance Principle 5:
*
The
Curious
Organization
Conklin/Railey
Drift and Accumulation
Normally
Successful!
*
The
Curious
Organization
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Conklin/Railey
The Power of
Early
Hazard
Solution Space
ID
Identified
or Discovered
Problem
The
Curious
Organization
Conklin/Railey
The Power of
Early
Hazard
ID
The
Curious
Organization
Solution Space
Conklin/Railey
*
Human Errors
70%
System Induced Error
Operational Upsets
30%
90%
Human
Error
10%
Equipment
Failures
Slip, trip or
lapse
*
OLD
*Human error is a cause of
accidents…
*To explain failure,
investigations must seek
failure
*They must find people’s
inaccurate assessments,
wrong decisions and bad
judgments
The
Curious
Organization
NEW
*Human error is a symptom of
trouble deeper inside a
system…
*To explain failure, do not try
to find where people went
wrong.
*Instead, find how people’s
assessments and actions
made sense at the time,
given the circumstances that
surrounded them.
Conklin/Railey
The Challenge…
Make it easy to
See problems
Swarm and Fix problems.
Spread new knowledge.
Lead by developing this capacity.
*Stephen
The
Curious
Organization
Spear, The High Velocity Edge
Conklin/Railey
Safety is not the
absence of
Accidents.
Safety is the
presence of
defenses.
The
Curious
Organization
Conklin/Railey