brownfields 2013 ron snyder, hmtri/ccchst adapted from: todd conklin phd los alamos national...

Brownfields 2013

Ron Snyder, HMTRI/CCCHST

Adapted from: Todd Conklin PhD

Los Alamos National Laboratory

Human Performanceand Learning –

The Next Steps

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 WayTo Improve SafetyIn 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

StartOfJob

MissionSuccess

*Planned Work

*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

People Are As Safe As They Need To Be,

Without Being Overly Safe…In Order To Get

Their Job Done.

Or Are They..

*Human Performance

“ 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

Worker’s Don’t Cause Failures.

Worker’s Trigger Latent Conditions That Lie

Dormant In OrganizationsWaiting for This Specific

Moment In Time.

*Failure Defined…

“Accidents are the unexpected combination of normal performance variability”

Eric Hollnagel

*Accidents Don’t Happen Because Workers Gamble and

Lose…

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

StartOfJob

MissionSuccess

Your WorkersAre Masters ofComplex AdaptiveBehavior…

Unclassified19

*Why Stop Work is easier to say than to do…

Clearly Safeto do Work

Clearly Not Safeto do WorkThe Grey Area:

Uncertaininterpretationof Safe work

HumanError

ExpertiseIdentification

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 scientificstudy combined with the experience of many years.

Finished files are the re-sult of years of scientificstudy combined with the experience of many years.

*Limitations of Human Nature

“Mistakes arise directly from the way the mind handles information, not through stupidity or carelessness.”

-Edward de Bono PhD

“Knowledge and error flow from the same mental sources, only success can tell one from the other.”

Ernst Mach, 1905

Events aren’t predictable,

But the environment in which Events are most likely to happen is…

1. Choose and number between 1 and 10

2. 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

DenmarkKangarooOrange

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

-Plato

Accumulation of Risk

StartOfJob

Hazard

Event

*Predictability

*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

“Risk that you can control are much less a source of outrage than risks you can NOT control.”

-Peter Sandman, PhD

*Risk Perceptions

*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.

Old 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

New View*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

Systems Thinking Is About Relationships…

Not About The Individual Parts of the Failure.

Unclassified 37

*Process Complexity

*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

Unclassified 38

*As systems become more complex

*Human errors become more complex

*More unanticipated situations exist

*More encounters in which procedures are not optimal

(work-arounds) or non-workable situations

Unclassified 39

*Purpose of Procedures?

Achieve success

or

Avoid failure

Unclassified 40

*The Complexity Conundrum

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.

Unclassified 41

*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

Event Prevention Happens Through

Learning.

Accumulation of Risk

StartOfJob

Hazard

Event

NormalWorkRisk

Understanding:Learning

Error without consequence is a good thing…

It shows that our systems are error-tolerant and that they

are working.

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 Up2. To Not Screw Up

*Traditional View of Error and Violation

Deviation fromExpectedBehavior

Error Violation

The Gray Area

“Intentional Variation”PotentialLearningTarget Area

*8 Questions A Manager Should

Ask

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?

*Organizations that do this well

do 4 things:

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.

You Manage Risk in order to…

Keep Failure From Being Successful.