Human Performance Improvement/ HRO Todd Conklin PhD Human Performance Improvement/ HRO Toddconklin@gmail.com

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.

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

Until They’re NOT…

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

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

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

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

Shift your thinking from “Why” to “How”

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

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

*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

1 People Make Mistakes… (All the time)

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

Human Error Expertise Identification Exercise

*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

Error is not a choice. Mistakes = Violations

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

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

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

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

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

Organizational Systems Drive Worker Behavior… 3

*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

Event Prevention Happens Through Learning. 4

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

Workers Are Masters of Complex Adaptive Behavior…

*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…

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

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

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

5 Management’s response to Events MATTERS…

Is the juice worth the squeeze?

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

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

*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

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

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

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.

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

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

Thanks Toddconklin@Gmail.com