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.