accident investigations - blame and shame or listen and learn?

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