accident investigations - blame and shame or listen and learn?
TRANSCRIPT
Deepwater Horizon Delusions Delusion of preventability and lineraity Examples of all accidents are preventable – lucky, Chemical factory Lac MeganBc Typical accident analysis – RCM steps Human error Killer Driver Human capability – ball girl, baseball player, The Accident Just culture repsonses AlternaBve methods Leadership link
“Blame ‘n shame” or
‘Listen and Learn”
A Just approach to Accident InvesBgaBon
NOSHCON September 2015 PresentaBon by Steve Woodward – SAFEmap InternaBonal
All accidents are preventable!! If we know the effect we can determine the cause
If we know the cause we can eliminate it
From this mindset it follows that….
We should never have an accident so why do we …well human error of course..
“Killer Driver”
“Killer Driver”
What was the cause?
Analyze and prevent accidents
Eliminate risk-‐taking
Enforce safety rules
Educate in safe work procedures
Engineer a safe work environment
Measure safety performance
Reward achievements
Zero
1. The delusion of causa=on 2. preventability 2. The delusion of human error 3. The delusion of compliance 4. The delusion of consistency 5. The delusion of control 6. The delusion of quan=fica=on 7. The delusion of invulnerability
Probable
Infrequent
Remote
Improbable
Marginal Cri=cal Catastrophic
Preventability
All accidents are preventable…
12 dead, 42 injured
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1.2 Aftermath
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…accident wai=ng
to happen…
Driver Change over
Thin tanker shells fail
Air release
Fire fighters shuts loco
911 call: Loco fire
All leave scene No loco started
Hand brakes fail
Parked on .92% gradient
Sets 7 handbrakes
Reports smoke to authority
Rushing
Complacent
FaBgue
Careless
DistracBon
A\tude
FrustraBon
Why?
Why? Why?
Why? Why?
WYLFIWYWF
hindsight
O_awa 18 September 2013 6 of 82 killed
Unknown risks Known risks
What?
What?
What?
What?
Average level of posi=ve responses “All accidents can be prevented”
0 0 20 30 40 50 60 70
Percent Agree Linear (Percent Agree)
More positive companies
Best safety performance
More negative companies
Worst safety performance
The Chemical Factory
1 2 3 4
The Chemical Factory
1000 40 1000 30 1000 20 1000 10
1. The delusion of causa=on 2. The delusion of human error
3. The delusion of compliance
4. The delusion of consistency
5. The delusion of control
6. The delusion of quanBficaBon
7. The delusion of invulnerability
Risk management: where are the keys?
“Virtual” risks Known risks
“Virtual” risks Known risks
Murphy’s Law according to Sidney Dekker
“ Most of the time what will go wrong goes right …. ….until it doesn’t ”
Luck?
TradiBonal View of Determining Incident Causes
Substandard Acts Substandard CondiBons
Personal Factors Job Factors
Incident
Immediate Causes
Underlying or Root Causes
Management System Deficiencies Incident Causa=on Path
Incident Inves=ga=on Path
No Standard, Inadequate Standard, Non-‐Compliance
“Finding th
e man
agem
ent system
deficiencies tha
t led
to th
e incide
nt”
Evolving View of Determining Incident Causes
Incident
Substandard Acts Substandard CondiBons
Immediate Causes
Human Factors Systemic Factors
ContribuBng Factors
Management System Deficiencies
No Standard, Inadequate Standard, Non-‐Compliance
Incident Causa=on Path
Incident Inves=ga=on Path
“Finding th
e man
agem
ent system
deficiencies tha
t led
to th
e incide
nt”
Physical Factors
Full InvesBgaBo
n Limite
d Inves=ga=o
n
Inves=ga=on Risk Calculator Exercises
• For each example provided, determine the following:
a) The Actual risk level and PotenBal risk level; b) The recommended team size (supervisor only, small team or full team);
and, c) The report type (limited invesBgaBon or a full invesBgaBon report)
"Ladies and gentlemen, thank you for flying with our Airline. Please make yourself comfortable..…
For those of you si?ng on the right side of the plane..… please ignore our other airliner."
A Cabin Announcement:
Anchor Error ! Severe accidents are overestimated
− For example: nuclear, sharks, guns
Anchor Error
Risk Finder
RISKcalculator
Happens here often
SeldomQuarterlyMonthlyWeeklyDailyContinuous
Fatalities
Fatality
Disability
Serious (LTI)
Medical
First Aid
Happened here previously
Can happen here
Heard of elsewhere
Never heard of it
Happened here recently
PLEASE PRINT CLEARLY
SupervisorEmployee▼ ▼
Likelihood
Exposure
Result
Risk Level
9
8
7
6
5
4
3
2
1
Circle a numberDraw your lines above
2 Very High High
Very L
ow
Low
Med
ium
1. Situation Entrance, work area, travel ways safe? What are the risks?
2. Arrangement Equipment, conditions, tools safe? What are the risks?
3. Fellow employees and Self Procedures, PPE, Trained, fit for the task?
4. Encourage Supervisor discuss Risks, Topic Supervisor discusses risks, encourages safe work.
5. Today Safe rest of shift? Other risks in shift? Positive reinforcement, Can and will I continue to work properly?
6. Yes Final check, Risks Overlooked, Underestimated, Ignored, Rewarded? Do an act of safety.
© 2009 SAFEmap International Pty. ✓ or ✖
Anchor Error
Risk Finder
RISKcalculator
Happens here often
SeldomQuarterlyMonthlyWeeklyDailyContinuous
Fatalities
Fatality
Disability
Serious (LTI)
Medical
First Aid
Happened here previously
Can happen here
Heard of elsewhere
Never heard of it
Happened here recently
PLEASE PRINT CLEARLY
SupervisorEmployee▼ ▼
Likelihood
Exposure
Result
Risk Level
9
8
7
6
5
4
3
2
1
Circle a numberDraw your lines above
2 Very High High
Very L
ow
Low
Med
ium
1. Situation Entrance, work area, travel ways safe? What are the risks?
2. Arrangement Equipment, conditions, tools safe? What are the risks?
3. Fellow employees and Self Procedures, PPE, Trained, fit for the task?
4. Encourage Supervisor discuss Risks, Topic Supervisor discusses risks, encourages safe work.
5. Today Safe rest of shift? Other risks in shift? Positive reinforcement, Can and will I continue to work properly?
6. Yes Final check, Risks Overlooked, Underestimated, Ignored, Rewarded? Do an act of safety.
© 2009 SAFEmap International Pty. ✓ or ✖
Risk Finder
RISKcalculator
Happens here often
SeldomQuarterlyMonthlyWeeklyDailyContinuous
Fatalities
Fatality
Disability
Serious (LTI)
Medical
First Aid
Happened here previously
Can happen here
Heard of elsewhere
Never heard of it
Happened here recently
PLEASE PRINT CLEARLY
SupervisorEmployee▼ ▼
Likelihood
Exposure
Result
Risk Level
9
8
7
6
5
4
3
2
1
Circle a numberDraw your lines above
2 Very High High
Very L
ow
Low
Med
ium
1. Situation Entrance, work area, travel ways safe? What are the risks?
2. Arrangement Equipment, conditions, tools safe? What are the risks?
3. Fellow employees and Self Procedures, PPE, Trained, fit for the task?
4. Encourage Supervisor discuss Risks, Topic Supervisor discusses risks, encourages safe work.
5. Today Safe rest of shift? Other risks in shift? Positive reinforcement, Can and will I continue to work properly?
6. Yes Final check, Risks Overlooked, Underestimated, Ignored, Rewarded? Do an act of safety.
© 2009 SAFEmap International Pty. ✓ or ✖
1. The delusion of linearity
2. The delusion of human error
3. The delusion of compliance
4. The delusion of consistency
5. The delusion of control 6. The delusion of quanBficaBon
7. The delusion of invulnerability
As humans, we can (uniquely) be:
! Ina_enBve ! Incompetent ! ErraBc ! Biased ! ViolaBng
• Lapsing • Forgetful • Unreliable • Inconsistent • Rigid
and complacent...!
As humans, we can (uniquely) be:
• Enduring • Compassionate • ImaginaBve • Sacrificing • Conquering
• Heroic • Passionate • Inspirational • Intuitive • Adaptive
Miner in tunnel
Capt Sully Sullenburger
Train Dilemma 4
Soldier picture
Pressures ExpectaBons
At-‐risk CircumvenBon
Perceptual
Technical skills Incompetence Misjudgment CogniBve error
Erroneous
Risk IncenBves Safe Punishment Poor Design Risky RouBnes
Delusions Calculated Careless Reckless
Conformant Inten=onal
IntenBonal Inadvertent
Change Train Discipline Coach
Pressures ExpectaBons
At-‐risk CircumvenBon
Perceptual
Technical skills Incompetence Misjudgment CogniBve error
Erroneous
Risk IncenBves Safe Punishment Poor Design Risky RouBnes
Delusions Calculated Careless Reckless
Conformant Inten=onal
Discipline Sanc=on Warning Punishment Rebuke