2. Human Performance Improvement/ HRO
Todd Conklin PhD
Human Performance Improvement/ HRO

3. Safety is not the absence of Accidents.
Safety is the presence of Capacity.
Safety is not the absence of Accidents.
Safety is the presence of Defenses.

4. Workers Are As Safe As They Need To Be,
Without Being Overly Safe…
In Order To Get The Jobs Done.

5. Until They’re NOT…

6. “To understand failure…we must first understand our reaction to failure.”
— Sidney Dekker
*Human Performance

7. Sharp End Blunt End Workers Highest Influence Over System Highest
Failure
Potential
Front-line
Supervisors
Managers
Leaders
Company
Customers
Regulators
Blunt End

8. Pre-Accident Investigations, Conklin 2013
3 Parts of an Event

9. Worker’s Don’t Cause Failures.
Worker’s Trigger Latent Conditions That Lie Dormant In Organizations Waiting for This Specific Moment In Time.

11. Shift your thinking from “Why”
to “How”

12. Workers fail…when we make it easy to do work incorrectly and hard to do work Reliably.

13. An Individual
Working within the organizational system…
To meet expectations set by leaders.
*Human Performance

14. *Human Performance Principles
People are fallible
Error-likely situations are predictable
Individual behaviors are influenced
Operational upsets can be avoided
Management’s response to failure matters
*Human Performance Principles

15. 1
People
Make
Mistakes…
(All the time)

16. Origin of Human Error Human Errors Operational Upsets
Slip, trip or lapse
Equipment Failures
Human Errors
Operational Upsets
System Induced Error
Origin of Human Error

17. Human
Error
Expertise
Identification
Exercise

18. *Limitations of Human Nature
“Mistakes arise directly from the way the mind handles information, not through stupidity or carelessness.”
-Edward de Bono PhD
*Limitations of Human Nature

19. Error is not a choice.
Mistakes =
Violations

20. Predicting
Events… 2
Human Beings are not good at predicting the future?

21. A reliable organization can spot an action going wrong… not an action gone wrong.

22. Events aren’t predictable,
But the environment in which
Events may happen is…

23. “The problem with the future is that more bad things can happen than will happen.”
-Plato

24. Risk-Important Actions and Critical Steps
November 10, 2009
All Procedure Steps
Example: Walking near a cliff
Absence of barriers or fences
Improve technique
Taking extra care
Pay attention
Margin – proximity of treadway to edge
Risk-Important Steps: procedure steps or actions that expose products, services, or assets to the potential for or actual harm. A process step that must be done right.
All Risk-Important Actions
Critical Steps
Critical Steps: actions that will trigger immediate, irreversible harm. A process that cannot be done wrong.
Risk-Important Actions (loose coupling situations)
Expose products, services, or assets to the potential for harm; increased chances of a significant error or malfunction
Significant human interaction:
frequent / multiple exposure of risk-important structures, systems and components to human fallibility
actual or potential changes in configuration
two or more mistakes away from an unwanted outcome
high degree of monitoring and control required by people – fine control within narrow limits
Reversible – nothing bad happens right way or slow change in state of asset; time available to avoid harm; can create the conditions for a critical step; loose coupling
Reduced margin to safety limits – reduces the reliability of equipment or defeats safety devices or functions
Latent Conditions – can create a hidden weaknesses that could cause harm later, if undetected
No energy transfer – or slow enough change in state to allow people to respond quickly enough to avoid the unwanted outcome
Critical Steps (tight coupling situations)
Significant human interaction – one mistake away from an unwanted consequence (harm); close proximity (touching)
Energy transfer – unwanted change in state (of asset) occurs (harm), or unwanted interruption of energy flow
Harm – degree of severity and types of outcomes to avoid; intolerable; not necessarily self-revealing
Irreversible – no undo; committed action; cannot return to original, previous condition by reversing the initiating action; point of no return
Immediate – outcome realized within moments upon taking action, whether recognized or not by the performer; tight coupling (high rate of change in system/asset; occurrence of consequences quicker than people can respond to avoid the outcome)
Risk-Important Actions and Critical Steps

25. Organizational
Systems
Drive
Worker Behavior… 3

26. *Organizational Processes
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
*Organizational Processes

27. Event Prevention
Happens Through
Learning. 4

28. The story of all the little events….
Collectively tells you where the next event may happen.

29. Workers
Are Masters of
Complex Adaptive
Behavior…

30. *Workers Discover Safety While Working…
The Gray Area:
Uncertain
interpretation
of Safe work
Clearly Safe
to do Work
Clearly Not Safe
to do Work
*Workers Discover Safety While Working…

31. *After the Event, Safety is Clear…
Clearly Safe
to do Work
Clearly Not Safe
to do Work
Event
*After the Event, Safety is Clear…

32. Reliability Understood: Drift and Accumulation
Normal
Work
Start Of
Job
Event
Context:
Learning
Event
Hazard
Reliability Understood: Drift and Accumulation

33. Performance Modes Hi Attention To Task RULE SKILL Hi
Translated from Jens Rasmussen
Human Errors: A Taxonomy for Describing Human Malfunction in Industrial Instillations
1:2
Mental Picture
Patterns
KNOWLEDGE
1:1000
Misinterpretation
If - Then
Attention To Task
RULE
1:10,000
Inattention
Automatic
SKILL Hi
Low
Familiarity With Task

34. 5
Management’s response to
Events MATTERS…

35. Is the juice worth the squeeze?

36. The Power of Early Hazard ID Solution Space Identified or Discovered
Problem

37. The Power of Early Hazard ID Identified or Discovered Problem
Solution Space
Identified
or Discovered
Problem

38. *How We See Events Old View New View
Human error is a cause of accidents
To explain failure, investigations must seek failures of parts of systems
These investigations must find inaccurate assessments and bad decisions
Human error is a symptom of trouble deeper inside a system
To explain failure, do not try to find out where people went wrong
Instead, find out HOW peoples’ actions and assessments made sense at the time given the circumstances that surrounded them.
*How We See Events

39. Active Trigger: Change in equipment, system, or process that triggers immediate undesired consequences. In other words, an active error has immediate harm and you know who did it.
Latent Condition: Result in undetected organization- related weakness or equipment flaws that lie dormant in the system.
Condition Types

40. Its pretty simple…You can Blame & Punish
Or Learn & Improve.

41. Make it easy to see conditions that are wrong.
…Swarm in and Learn and Fix.
Spread the news across the Site.
Leave the capacity for the people to do it again – themselves.

42. Safety is not the absence of Accidents.
Safety is the presence of Defenses.

43. Keep Failure From Being Successful.
What you do is…
Keep Failure From Being Successful.

44. Thanks