3 ObjectivesReview the traditional ways of approaching safety, their assumptions, and their implicationsIdentify factors that influence human performanceList new ways of thinking about and approaching safetyPaul
4 Why do they do what they do? PaulYou just can’t fix stupid!
5 The “bad apple” theorySome (most) people don’t care enough about safety to be safeSome (most) people don’t know enough about safety to be safeRonThese people are the primary cause of accidents
6 What is the underlying assumption? Our systems are essentially safePeople make it unsafe through violations and human errorWe (safety pros, regulators, managers, etc.) know the safest way to do the jobAny deviation is, therefore, unsafe (stupid)Ron
7 Traditional Safety Thinking The best way to intervene is at the behavioral levelSafety is best measured by its absence (injuries, incidents, risk)People are unreliable and are a problem to controlRon
8 Hearts and Minds Strategies Management SystemsThe best way to intervene is at the behavioral levelSafety is best measured by its absence (injuries, incidents, risk)People are unreliable and are a problem to controlSOPsIncident RatesBBSSafety Rules/DisciplineRegulations/ComplianceRonTrainingEMRsReliance on Technology
9 Is the juice worth the squeeze? BUT…Is the juice worth the squeeze?Paul
10 Let’s make some new assumptions Most people don’t do things that they think gets them hurtMost people don’t do things that they think will hurt othersMost people don’t do things that will cause them to do a bad jobPaulPeople do things that they think will help them achieve their goals
12 Is this the most efficient/productive way to do the job? What’s this guy doing?Is this the most efficient/productive way to do the job?Paul
13 What’s that? What’s that? PaulWhy would he choose to stand on the rails if he had the tools to do the job?
14 When we look closer at “stupid” behavior… We find that it’s not so stupidIt’s people responding toVaried environmentsScarce resourcesCompeting goalsUnclear risksRonAnd they’re normally successful!
15 Now, nobody’s putting a gun to their heads… True, but all actions have consequencesWhat happens if they don’t do the work?What happens if they do?RonIt is difficult to get a man to know something when his salary depends on his not knowing it.-Upton Sinclair
16 But actions should have consequences… True, but often the consequences provided do not achieve the goalsJustice – People are often punished for outcomes, not actionsSafety – We’ve had behavior controls throughout history and people are still dyingRon
17 Quick Reality Check What we are NOT saying What we are saying That laws should go unpunishedThat rules, procedures, etc. do not have a placeWhat we are sayingCurrent approaches may be missing the markPaulAsk not who’s to blame, ask what’s to blame
18 The bottom line…What we see as “stupid” is often just people applying strategies that normally workPaulIf we eliminate those strategies before we understand them, we might be shooting ourselves in the foot
19 Human Performance 101 Help them apply better strategies Give them complete information about the risks they faceProvide them with an accurate mental model of the systemEnsure they have adequate resources to do the job (resilience)Make systems forgiving (error tolerant)Provide coping skills for managing trade-offsRon
20 BP Texas City Refinery 2005 Unclear risks Inaccurate mental model Inadequate resourcesUnforgiving systemCompeting goalsRonSource: Hopkins (2008)
21 A Learning CultureAfter an event, you have to choose between LEARNING and BLAMEYou can’t do bothBefore an eventNormal accountability structures applyAfter an eventThe organization is accountable to learn from the eventPaulThe root of the word “accountability” is to make an account of what actually happened.
23 Safety, DifferentlyThe best way to intervene is at the contextual levelSafety is best measured by its presence (i.e. success)People are usually reliable and are the source of safety and successRon
24 SummaryReviewed the “bad apple” theory and why its assumptions are not trueIdentified factors that influence the choices people makeListed strategies to enhance human performance, such as:Help them make informed adjustments to their environmentsStop being surprised by error! Start learning from it!Ron
25 Paul Gantt, M.Eng, CSP, CET Ron Gantt, M.Eng, CSP, CET Questions?Paul Gantt, M.Eng, CSP, CETRon Gantt, M.Eng, CSP, CETRonSlides/more info available on our website: