The Misfortune Murphy Model
• Will help us understand how human errors result
in accidents
• Will assist us in understanding the root causes to
an accident
• Will illustrate the role of Safety Management
Systems (SMS) in preventing accidents
• Will help us understand what WE can do to help
prevent future accidents
Latent Conditions
Management Decisions
• Management Decisions set up “Latent Conditions”
Latent Conditions
A system condition (policy, decision or
“norm”) that lays dormant until an active
failure normally brings it to light
They are there but often not recognized as
dangerous until too late
Management Decisions
• Management Decisions set up “Latent Conditions”
• Set the “scene” for the Active Failure to occur
• Seem like good ideas at the time
• May lay dormant for a long time
• When all the conditions are “wrong” an accident
occurs if there is no Safety Net to stop it.
• The Safety Net may be present however it has a hole
in it (not being followed)
Latent Conditions
Latent Conditions
Line Management Decisions
• Line Management Decisions “Latent Conditions”
• Are decisions made based on what they think the
management really wants
• Are there but are not recognized as potentially
dangerous
• May also lay dormant for a long time
• When all the conditions are “wrong” an accident
occurs if there is no Safety Net to stop it
• The Safety Net may be present however it has a
hole in it (not being followed)
Latent Conditions
Latent Conditions
Latent Conditions
Preconditions - The Dirty Dozen
• Set the person up to make the active error
• Are often a combination of more than one of the
Dirty Dozen
1. Lack of Communication 7. Lack of Resources
2. Complacency
8. Pressure
3. Lack of Knowledge
9. Lack of Assertiveness
4. Distraction
10. Stress
5. Lack of Teamwork
11. Lack of Awareness
6. Fatigue
12. Norms
Active Failures
Latent Conditions
Latent Conditions
Latent Conditions
The Active Failure
The “guilty party” who makes the mistake
that results in a human error
It will be an action or lack of action that
results in the error
It is the RESULT but NOT the CAUSE
Active Failures Are Usually Productive
Activities That Involve an Unsafe Act
•
Is
usually
very
experienced
The
“Guilty
Party”
The Guilty Party
• Has no intention of making
the error (He knows better)
• Often has no idea how he
could have been so
“careless”
• Will often punish himself
more than the system can
• Is very unlikely to ever do
it again
Active &
Latent
Failures
Active Failures
Latent Conditions
Latent Conditions
Latent Conditions
Safety Nets
• Last chance to prevent the accident from
occurring
• If there is no Safety net in place then it is a
Latent Failure
• The Safety Net may be present however it
has a hole in it (not being followed)
• If the Safety net is not being used it is an
Active Failure
How many times does the chain of events get all
the way to the Safety net and is stopped there?
Active &
Latent
Failures
Active Failures
Latent Conditions
Latent Conditions
Latent Conditions
The SMS Incident Drip Tray
• Serves to catch the “near misses” that could
have continued on to cause an accident
• Requires someone to “fess up” and report the
“near miss”
• Requires a system to take and analyze (risk
assess) the data in the “drip tray”
• The system will then use this information to
“plug or reduce the size of some of the holes”
that allow the chain of events to occur
• This results in fewer accidents
• We learn from an accident we didn’t have
10-20%
Active &
Latent
Failures
Active Failures
Latent Conditions
Latent Conditions
Latent Conditions
YOU Are the Key to Safety
• YOU are the person who has the “near misses”
• YOU are the one who can put information into
the “Incident Drip Tray”
• YOU can provide the information that will help
“plug the holes”
• YOU can provide the “Free Lessons” that
enable the organization to learn without having
to have an accident
• SMS will require YOUR input to work