Presentation is loading. Please wait.

Presentation is loading. Please wait.

Todd Conklin PhD Sr. Safety Advisor Los Alamos National Labs The Curious Organization Royce Railey Regional S&H Manager Cintas Corporation.

Similar presentations


Presentation on theme: "Todd Conklin PhD Sr. Safety Advisor Los Alamos National Labs The Curious Organization Royce Railey Regional S&H Manager Cintas Corporation."— Presentation transcript:

1 Todd Conklin PhD Sr. Safety Advisor Los Alamos National Labs The Curious Organization Royce Railey Regional S&H Manager Cintas Corporation

2 Never take a sleeping pill And a laxative At the same time… …In any order Conklin/Railey The Curious Organization

3 Safety is not the absence of Accidents. Safety is the presence of defenses. The Curious Organization Conklin/Railey

4 The Curious Organization Conklin/Railey

5 “ To understand failure…we must first understand our reaction to failure. ” — Sidney Dekker The Curious Organization Conklin/Railey

6

7 The Curious Organization Ask How Not Why ! Conklin/Railey

8 We Must Manage Worker Behavior and Work Processes In Parallel… The Curious Organization Conklin/Railey

9 9 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 Organization Conklin/Railey

10 Human Performance Principle 1: Conklin/Railey

11 Human Error Expertise Identification Exercise The Curious Organization Conklin/Railey

12 12 How many times does the uppercase or lowercase letter“F”appear in the following sentence? Finished files are the re- sult of years of scientific study combined with the experience of many years. Finished files are the re- sult of years of scientific study combined with the experience of many years. The Curious Organization Conklin/Railey

13 “Mistakes arise directly from the way the mind handles information, not through stupidity or carelessness.” -Edward de Bono PhD The Curious Organization Conklin/Railey

14 Error is not a choice. Mistakes Violations = The Curious Organization Conklin/Railey

15 Workers Are Masters of Complex Adaptive Behavior… The Curious Organization Conklin/Railey

16 Unclassified 16 Clearly Safe to do Work Clearly Not Safe to do Work The Gray Area: Uncertain interpretation of Safe work The Curious Organization Conklin/Railey

17 Unclassified 17 Clearly Safe to do Work Clearly Not Safe to do Work Event The Curious Organization Conklin/Railey

18 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

19 Human Performance Principle 2: The Curious Organization Conklin/Railey

20 Events aren’t predictable, But the environment in which Events may happen is… The Curious Organization Conklin/Railey

21 Where will the next safety event happen at your site? Conklin/Railey

22 The story of all the little events…. Collectively tell the STORY of where the next event may happen. Conklin Conklin/Railey

23 Human Performance Principle 5: The Curious Organization Conklin/Railey

24 24 Normally Successful! The Curious Organization Conklin/Railey Drift and Accumulation

25 Solution Space The Power of Early Hazard ID Identified or Discovered Problem The Curious Organization Conklin/Railey

26 Solution Space Identified or Discovered Problem The Power of Early Hazard ID The Curious Organization Conklin/Railey

27 Human Error Slip, trip or lapse Equipment Failures Human Errors Operational Upsets System Induced Error

28 Conklin/Railey The Curious Organization * 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 * 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. OLD NEW

29 Make it easy to See problems Swarm and Fix problems. Spread new knowledge. Lead by developing this capacity. * Stephen Spear, The High Velocity Edge The Challenge… The Curious Organization Conklin/Railey

30 Safety is not the absence of Accidents. Safety is the presence of defenses. The Curious Organization Conklin/Railey


Download ppt "Todd Conklin PhD Sr. Safety Advisor Los Alamos National Labs The Curious Organization Royce Railey Regional S&H Manager Cintas Corporation."

Similar presentations


Ads by Google