ben cook - ahspo
TRANSCRIPT
Empowered Accountability & Error Control AHSPO 6 August 2015
www.hse3.com.au
Copyright Convergent Performance – Human
and Systems Excellence
Zooming Out of the Mud:
Empowered Accountability &
Error Control
Ben CookCEO, Human & Systems Excellence
AHSPO, Yarra Valley Lodge
6 August 2015
Scope
Acknowledgements
Dr Tony Kern, CEO Convergent
Performance (Blue Threat IP)
The winner of multiple national and
international awards for aviation
safety and program management and
the author of six books on aviation
professionalism
http://www.convergentperformance.com/
The Four Questions
• Who is this guy…
• What qualifies him to talk to me about
my profession…
• How long is he going to talk…
• Is any of this testable?
Top Guns vs Medical Procurement?
Alan Lilly (CEO Eastern Health):
• Egos
• Strong work ethic; Can-do culture
• If you only seek good you won’t be great
• Requires disciplined people
• When it goes wrong:
• there are often lessons that were not
learnt the first time (NHS – North
Staffordshire)
Empowered Accountability & Error Control AHSPO 6 August 2015
www.hse3.com.au
Copyright Convergent Performance – Human
and Systems Excellence
RoE: Participant Feedback Participant Response Clickers
Select a response:
Working – flashing green lightNot sure – orange light – press again
To select 10 press the 0/J key
CLICKER TEST: The prime minister is doing a good job?
1. 2.
69%
31%
1. Yes
2. No
I’m here today because…
1. 2. 3. 4.
58%
27%
3%
12%
1. I benefit and enjoy industry seminars
2. The boss sent me – I have to be here
3. I’m not meant to be here but I’m too embarrassed to admit it
4. I don’t know but I’m enjoying the alcohol
Years of Medical Procurement Experience?
11%
2%
13%
19%
23%
33%1. 0-5
2. 5-10
3. 10-15
4. 15-20
5. 20-25
6. 25+
With consideration to Alan Lilly’s presentation last night, the culture in my workplace is on track to support the journey from good to great?
1. 2.
45%
55%1. Yes
2. No
Empowered Accountability & Error Control AHSPO 6 August 2015
www.hse3.com.au
Copyright Convergent Performance – Human
and Systems Excellence
Human Factors?
The minimisation of human error
and its consequences by optimising
the relationship within systems
between people, activities and
equipment
Humans remain a significant force
multiplier….
Humans remain a significant force
multiplier….
NAVY ARMY AIR FORCE
QF32
“BOOM”…”BOOM”
• 7,400ft
– Alt Hold, Hdg Sel, Thrust
– “PAN – will contact in a
few minutes”
Warning: ENG 4 OVERTHRUST PROT LOST (not displayed)
Warning: ENG 1 OVERTHRUST PROT LOST (not displayed)
Warning: F/CTL ALTN LAW (PROT LOST)
Warning: ELEC C/B TRIPPED
Warning: ENG2 FIRE
Warning: FUEL R INR TK FWD+AFT PMPs FAULT
Warning: VENT COOLG SYS 1 OVHT
Warning: BRAKES A-SKID FAULT ON WING L/Gs
Warning: BRAKES NORM BRK PRESS MONITORING FAULT (not displayed)
Warning: BRAKES ALTN BRK PRESS MONITORING FAULT (not displayed)
Warning: L/G CTL 2 FAULT
Warning: ELEC AC BUS 2 FAULT
Warning: ELEC DRIVE 1 DISCONNECTED
Warning: AIR L INR WING LEAK
Warning: AIR ENG 2 BLEED LEAK
Warning: AIR L OUTR WING LEAK
Warning: CABIN DRAIN MASTS HEATING FAULT (not displayed)
Warning: COND FWD CARGO VENT FAULT
Warning: HYD G FUEL HEAT EXCHANGER VLV FAULT (not displayed)
Warning: FUEL JETTISON VLV NOT CLOSED
Warning: FUEL FEED TK2 : MAIN+STBY PMPs FAULT
Warning: FUEL NORM+ALTN XFR FAULT
Warning: FUEL ENG 2 LPVLV FAULT (not displayed)
Warning: FUEL L INR TK FWD+AFT PMPs FAULT
Warning: F/CTL L MID AILERON FAULT
Warning: F/CTL L OUTR AILERON FAULT
Warning: F/CTL R OUTR AILERON FAULT
Warning: HYD Y ENG 4 PMP A PRESS LO
Warning: HYD Y ENG 4 PMP B PRESS LO
Warning: HYD G RSVR AIR PRESS LO
Warning : HYD G RSVR LEVEL LO
Warning: HYD G SYS PRESS LO
Warning: ELEC DRIVE 2 DISCONNECTED
Warning: ENG 2 SHUTDOWN
Warning: ENG 1 SENSOR FAULT (not displayed)
Warning: ENG 1 NORM+ALTN MODES FAULT
Warning: ENG 2 FAIL
Warning: ENG 2 IGN A FAULT (not displayed)
Warning: ENG 4 NORM+ALTN MODES FAULT
Warning: ENG 1 FIRE LOOP A FAULT (not displayed)
Warning: ENG 2 FIRE DET FAULT
Warning: ENG 2 REVERSER MINOR FAULT (not displayed)
Warning: ENG 2 NORM MODE FAULT
Warning: ENG 2 LP SHAFT PROT LOST (not displayed)
Warning: ENG 2 FADECSYS FAULT (not displayed)
Warning: ENG 2 OVERTHRUST PROT LOST (not displayed)
Warning: ENG 2 SLAT SYS 1+2 FAULT
Empowered Accountability & Error Control AHSPO 6 August 2015
www.hse3.com.au
Copyright Convergent Performance – Human
and Systems Excellence
Electronic Centralised Aircraft Monitor (ECAM) Actions
130 Faults (Total)– 58 Cockpit (~ 43 displayed, Misc
Overweight Landing, )
– 38 Cabin
– 19 Pending (incl ENG 1 Master, EEC1, EEC 4, GPWS 1+2 Fault)
– 15 Minor (ADIRU 1 & 3 wiring)
87 non displayed messages (ACARS to QF)
– 13 x ice protection
– 47 x wiring harness faults
– 1 x FDAC-1 (flight data accumulator)
– 1 x SATCOM
Info– CG OUT OF LIMITS FOR LANDING
– TRANSFER TRIM TK FUEL
– TRIM TK NOT USEABLE
– TRANSFER SYS INOP
Spend more time understanding what’s working well and why.
Clone those processes!!
For example: Eastern Health (Rohan Pal)
Bright Spots?
Workplaces & Society: Global Trends?
Distractions
Workload
Serious incidents &
accidents: predictable &
preventable.
Over the past 10 years, the NTSB has investigated numerous accidents that have demonstrated time and again the danger of using portable electronic devices while operating a vehicle, plane, train, or vessel.
Talking hands-free on a cell phone led to a seasoned motor coach driver colliding with a bridge in Alexandria, Virginia, in November 2004.
Pilots overflew their destination, Minneapolis-St. Paul International Airport, by 100 miles in October 2009 because they were distracted by their laptops.
In September 2008, an engineer ignored a red signal while texting, resulting in a head-on collision near Chatsworth, California, and 25 deaths.
The use of portable electronic devices in transportation has led to an increased number of crashes and an increased number of deaths.
NTSB: Distractions
Empowered Accountability & Error Control AHSPO 6 August 2015
www.hse3.com.au
Copyright Convergent Performance – Human
and Systems Excellence
Distractions & You?
A baby boy approaching
his first birthday died
after being left in a car
found in front of a day
care centre.
Distractions: October 2013
…the important factors that keep showing up
involve a combination of stress, emotion,
lack of sleep and change in routine…
In my workplace I believe we have a problem with unmanaged distractions leading to degraded performance and/or potential safety issues?
1. 2.
30%
70%
1. Yes
2. No
Insanity: doing the same thing over
and over again and expecting
different results.
Albert Einstein
Route Check
1
2
3
Emerging Human Performance Challenges
Blue Threat: A New Approach to Error Management
The Influence of Culture and Supervisors
4 Why Good Enough Really Isn’t
Empowered Accountability & Error Control AHSPO 6 August 2015
www.hse3.com.au
Copyright Convergent Performance – Human
and Systems Excellence
Short Break – Stand Up & StretchThe Four Questions
• Who is this guy…
• What qualifies him to talk to me about
my profession…
• How long is he going to talk…
• Is any of this testable?
How many “Safety 101” lectures should anyone
be subjected to in their lives?
Advanced Human Factors
The Return of Personal Accountability in
the Age of System Safety
Empowered Accountability & Error Control AHSPO 6 August 2015
www.hse3.com.au
Copyright Convergent Performance – Human
and Systems Excellence
Experts See A Different World
The purpose of this Blue Threat
curriculum is to empower each individual
to see deeper into the situation & deeper
into themselves to prevent errors and
continuously improve.
Blending Organisational
Management and Self Control Manage (mán·age) transitive verb
to oversee processes for running something
such as a store, department, or project;
to guide and control business affairs
Control (con·tról) transitive verb
to exercise power or authority over something; to
limit or restrict somebody or something in
expression, occurrence, or rate of increase
Error management needs to occur at the team and
organisational levels, but error control is personal.45
See Trouble Coming Sooner
Point of
Perception
and Detection Accident or Incident
Onset of Awareness
Time
Window of
Threat &
Opportunity
Enlarge the playing field and
time available to respond
Aggressively respond to
opportunities and threats as
they arise with new tools
Stay further ahead
of the situation
A Few New Terms and Concepts Why the Blue Threat?
The key to victory over the randomness
and variability of human error is first to
realise that error is only random in a
group setting. When you get down to a
sample size of one – you – error is both
predictable and preventable.
Empowered Accountability & Error Control AHSPO 6 August 2015
www.hse3.com.au
Copyright Convergent Performance – Human
and Systems Excellence
Procedures
Planning, Checklists, etc.
“Key knowledge is in the work”
Person
Self Awareness, Situation
Awareness, Judgement
“Key knowledge is in the person”
Completely
RoutineTotally
Unexpected
Attention
Distraction
Information Overload
Complacency
Boredom
Span of Control
Stress Induced Error
Noncompliance
Panic
Mastery Across Every Level of Challenge
Adapted from Jensen, Csikszentmihali, Reason and Kern
Expert’s
Curse Procedures
Planning, Checklists, etc.
“Key Knowledge is in the Work”
Person
Self Awareness, Situation
Awareness, Judgment
“Key Knowledge is in the Person”
Completely
RoutineTotally
Unexpected
Attention
Distraction
Information Overload
Complacency
Boredom
Span of Control
Stress Induced Error
NoncompliancePanic
Where is the real risk?
Adapted from Jensen, Csikszentmihali, Reason and Kern
Risk = severity X exposure
What skills are needed to manage the
Blue Threat?What skills are needed to manage the Blue Threat?
Mature Self Assessment
Can I objectively see and accept responsibility
for my weaknesses and mistakes?
What don’t I know that I need to?
What skills don’t I have that I need?
Empowered Accountability & Error Control AHSPO 6 August 2015
www.hse3.com.au
Copyright Convergent Performance – Human
and Systems Excellence
Habit Patterns: Distraction Control
Systems
Job Skills
Self
Management
Procedures
Our Training System:Still Vulnerable, Primed and Prone to Error
Blue Threat
Technical Training
Blue Threat Professional Development ProgramSelf Leadership – Known Competencies – Predictable Results
Peer to Peer
Accountability
Discipline
and ComplianceContinuous
Improvement
Personal
Error Control
Technical Training
Technical Training
UnknownT
ec
hn
ica
l Tra
inin
g
Te
ch
nic
al T
rain
ing
Self Leadership
Known Competencies
Predictable Results
Team Training
Team
Tra
inin
g
Team
Tra
inin
g
Team Training
Fatal Flaw in Our Thinking
It has long been assumed that when you train
someone to do something right you are
simultaneously training them not to do it wrong.
This simple premise is grossly in error and is
responsible for thousands of lost lives and billions
in lost revenue every year in high risk industries.
Seeds of Complacency We also assume since we have never
had an accident or incident, our current
behaviors are safe – even if its not the
best we can do or we do not precisely
conform to all policies or procedures.
Fact: Things that have never happened
before, happen all the time.
Empowered Accountability & Error Control AHSPO 6 August 2015
www.hse3.com.au
Copyright Convergent Performance – Human
and Systems Excellence
Continuous
updating of
procedures
to avoid
recurrence
of past
accidents
and
incidents
History
of system
Scope of
regulated
action
Actions sometimes
necessary to get the job done
Source. Human Error. Reason. 1990
Good policy and procedures are organizationalcornerstones.
Compliance is an individual cornerstone.
Red Rules, Green Rules and
Brown Rules
“Follow the rules
or change them,
there is no other
good choice.”
Guidance
Policy Norms
Operational Performance
Results
Procedures Techniques
DiscretionaryMandatory
When Cultural Norms Trump Policy
Purpose
“Go” Fight
Source. Blue Threat. Kern. 2010
“Slow” Fight
Regulation
Government
Equipment Manual
Standards Authority
Standard Workplace Procedures
Organisation/Company
Department
Safety Management System
Self-Discipline
You
Without Personal Professional Discipline, Safety
Management Systems Disintegrate from Within
Copyright Kern, Ryan and Agostino, 2005
Conventional Wisdom on Human Error
“People will always make mistakes, that’s a given.”
“It’s easier to change situations than people.”
“To err is human . . . it is easier to manage error than to
prevent it.”
“Human error mishaps are just the cost of doing
business.”
“We are forced to work with the crooked timber of
human fallibility.”
“Serious human factors experts moved beyond the
individual error approach 20 years ago.”
“The weakest link in the cockpit is wearing a headset.”
Blue Threat Proverb #29
“Only human” is the ultimate oxymoron.
Empowered Accountability & Error Control AHSPO 6 August 2015
www.hse3.com.au
Copyright Convergent Performance – Human
and Systems Excellence
So What?
I disagree with the conventional wisdom on error.
I believe that human error is not inevitable nor “part
of being human” any more than cancer is.
Errors do happen, but most can be controlled with
little more than enhanced knowledge and serious
personal intent.
Cancer Death Rates* by Sex, 1975-2005
Source: US Mortality Data 1960-2005, National Centre for Health Statistics, Centres for Disease Control and
Prevention, 2008.
0
50
100
150
200
250
300
1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005
Men
Both Sexes
Rate Per 100,000
Women
How was this trend
reversed with an
ageing population?
We learned what was
causing it and did a
few things differently.
Close Fight
M
i
s
h
a
p
R
a
t
e
Time
Engineering, Technology, Tools
and Equipment
Safety Systems, Processes
and Procedures, Team
Training
Safety Culture
Personal
Behaviours
“The challenge of human
error will never be
remedied by any traditional
training or safety program.
Personal error must be
slowly untangled – in a
private battle within each
individual.
Blue Threat, Tony Kern, 2010
This is true because in high achievers, human error
and personal weakness is secret and sacred ground;
at least until the accident investigators and lawyers
show up after the fall.”
Short Break – Stand Up & Stretch
Wrap up: Why “Good Enough”
Really Isn’tEmpowered Accountability Through
Continuous Improvement
The Next Generation of Human Factors
Empowered Accountability & Error Control AHSPO 6 August 2015
www.hse3.com.au
Copyright Convergent Performance – Human
and Systems Excellence
Blue Threat Levels of Effort and Competency
As little as you want – as much as you need.
My current level of Blue Threat competence?
10%
16%
26%
25%
18%
4%
1. Level 1 – Uninformed Status Quo
2. Level 2 - Awareness
3. Level 3 - Process
4. Level 4 - Analysis
5. Level 5 - Procedures
6. Level 6 - Habit
Accident
Incident
Violation
Hazard
Fatality
Safety
Effectiveness
Efficiency
Precision
Perfection
“Good Enough”
The crushing grip
of mediocrity
Performance Evolution Ladder – Copyright 1998 T. Kern
True safety, quality and
sustainability live here
Survival
Reaching for precision – Will it be there?
There are times when precision is
required; when “good enough” isn’t
anymore.
Maybe only 1 time in 1000, or even
1 in 10,000 but you don’t get to
choose the time of reckoning.
Why should we expect to perform
under extreme conditions at levels
we do not practice for on a daily
basis?
Accident
Incident
Violation
Hazard
Fatality
Safety
Effectiveness
Efficiency
Precision
Survival
Perfection
Performance Evolution Ladder – Copyright 1998 T. Kern
Accuracy without precision is
usually good enough to earn a
salary, but not always good
enough to survive
A perfect
day?
New Optics
When viewed through the enlightened
eyes of individuals, the vast majority of
“random errors” are predictable.
Predictable is preventable.
Empowered Accountability & Error Control AHSPO 6 August 2015
www.hse3.com.au
Copyright Convergent Performance – Human
and Systems Excellence
Critical Incident Technique
(Flanagan, Andersson, others)
Human Error Assessment and Reduction Technique
(modified)
(HEART)
Williams, J. T.; FAA Human Factors Workbench
Violation Producing Conditions
(Hawkins, Maurino, Reason, Kern, others)
Hazardous Attitudes
(FAA, Helmreich, others)
Cognitive Bias(Cortes, Crosskerry, others)
Situational Factors
Group Induced Errors
(various)
Risk Mgt(US Army, USAF, USN, USMC,
others)
The “expert’s curse” includes ______
1. Span of control, distraction, panic
2. Apathy, distraction, loss of SA
3. Complacency, non compliance, boredom
4. All of the above
1. 2. 3. 4.
4%
50%
45%
1%
Procedures
Planning, Checklists, etc.
“Key knowledge is in the work”
Person
Self Awareness, Situation
Awareness, Judgement
“Key knowledge is in the person”
Completely
RoutineTotally
Unexpected
Attention
Distraction
Information Overload
Complacency
Boredom
Span of Control
Stress Induced Error
Noncompliance
Panic
Mastery Across Every Level of Challenge
Adapted from Jensen, Csikszentmihali, Reason and Kern
Expert’s
Curse
Summary and Takeaways?
• New tools (self management) to enhance individual & team performance
• Return on investment – empowered & focused (home and work)
• Maintain & enhance professionalism even when confronted by poor workplace culture &/or the experts curse
• If not you - next generations need it more than ever!!!
What does good to great really look like? Presentation Critique
Empowered Accountability & Error Control AHSPO 6 August 2015
www.hse3.com.au
Copyright Convergent Performance – Human
and Systems Excellence
Ben was clear and easy to understand?
NAVY ARMY AIR FORCE
0%
1%
0%
2%
41%
56%1. Strongly agree
2. Agree
3. Slightly agree
4. Slightly disagree
5. Disagree
6. Strongly disagree
97%
Ben demonstrated thorough knowledge of the topic area?
NAVY ARMY AIR FORCE
0%
0%
1%
5%
39%
55%1. Strongly agree
2. Agree
3. Slightly agree
4. Slightly disagree
5. Disagree
6. Strongly disagree
94%
Ben engaged the audience and held attention easily?
NAVY ARMY AIR FORCE
0%
0%
2%
3%
27%
67%1. Strongly agree
2. Agree
3. Slightly agree
4. Slightly disagree
5. Disagree
6. Strongly disagree
94%
The information was relevant?
NAVY ARMY AIR FORCE
1%
1%
2%
12%
45%
39%1. Strongly agree
2. Agree
3. Slightly agree
4. Slightly disagree
5. Disagree
6. Strongly disagree
84%
10: Very positive, excellent information and learning experience
5: Just over the line but could be much better
1: Very negative, poor information not relevant
The Scoring System (out of 10)With consideration to the presentation
Clicker - To select 10 press the 0/J key (bottom, middle)
Overall Presentation Score?
A. 1.B. 2.C. 3.D. 4.E. 5.F. 6.G. 7.H. 8.I. 9.J. 10.
1. 2. 3. 4. 5. 6. 7. 8. 9.10.
2% 2%
0%1%
39%
24%
18%
11%
1%1%
81%
Empowered Accountability & Error Control AHSPO 6 August 2015
www.hse3.com.au
Copyright Convergent Performance – Human
and Systems Excellence
Further Support
Ben Cook
0403 536 552
www.hse3.com.au