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.

Work as Planned Start Of Job Mission Success

* 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

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 all- powerfully. 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

“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.

Work as Done Start Of Job Mission Success

Your Workers Are Masters of Complex Adaptive Behavior…

Unclassified 19 Clearly Safe to do Work Clearly Not Safe to do Work The Grey Area: Uncertain interpretation of Safe work

Human Error Expertise Identification Exercise

21 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.

“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. Choose and number between 1 and Multiply that number by 9 3. Add the two digits of this number together 4. Subtract 5 from this new number 5. Translate this number to a letter – 1 = A, 2 = B… 6. With this letter – choose a country that starts with that selected letter 7. With the last letter of this country – choose an animal 8. With the last letter of this animal – choose a fruit

Denmark Kangaroo Orange

Accumulation of Risk Start Of Job Hazard Event

* 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

“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 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.

Unclassified37 * 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 non- workable

Unclassified38 * Human errors become more complex * More unanticipated situations exist * More encounters in which procedures are not optimal (work-arounds) or non-workable situations

Unclassified39 Achieve success or Avoid failure

Unclassified40 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.

Unclassified41 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

Event Prevention Happens Through Learning.

Accumulation of Risk Start Of Job Hazard Event Normal Work Risk Understanding: Learning

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 Deviation from Expected Behavior Error Violation The Gray Area “ Intentional Variation ” The Gray Area “ Intentional Variation ” Potential Learning Target Area

1. Are the people ok? 2. Is the facility safe and stable? 3. Tell me the story of what happened? 4. What could have happened? 5. What factors led up to this event? 6. What worked well? What failed? 7. Where else could this problem happen? 8. 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.