Dealing with ErrorsBrian Landberg

2011-Sep-29

““The fool doth think he is wise, but the wise man knows himself to be a fool.” –W.Shakespeare

Outline

0. Background and Story

I. Preventing

II. Dealing

III. Recovering

Why This Topic? Why Me?

• Read a Pulitzer Prize winning article. Deeply moved.

• My career and experiences living in Japan have frequently led me to examine the process of not only risk assessment, but also dealing with mistakes.

• My own life is marked with various near misses, and I feel intense gratitude for the many people who have helped me to continue my journey each time.

Opportunities to learn from near misses (Heinrich’s law), as well as the tragedies of others.

The main story: Fatal Distraction (WSJ)

Various cases of typical, hard-working, busy parents who commuted to work as usual one sunny day, first dropping off the baby/toddler at daycare on the way, then parking at the office and reporting to work…

Only this day was different. The error is irreversibly tragic.

*The most horrifying thing about this story is to realize that none of us are immune to the kinds of terrible mistakes described.

Fatal Distraction (excerpts WSJ,2009/2/27)

“The facts are often the same: An otherwise loving and attentive parent one day gets busy, or distracted, or upset, or confused by a change in his or her daily routine, and just... forgets a child is in the car. It happens that way somewhere in the United States 15 to 25 times a year.Two decades ago, this was relatively rare. But in the early 1990s, car-safety experts declared that passenger-side front airbags could kill children, and they recommended that child seats be moved to the back of the car; then, for even more safety for the very young, that the baby seats be pivoted to face the rear. If few foresaw the tragic consequence of the lessened visibility of the child . . . well, who can blame them? What kind of person forgets a baby? The wealthy do, it turns out. And the poor, and the middle class. Parents of all ages and ethnicities do it. Mothers are just as likely to do it as fathers. It happens to the chronically absent-minded and to the fanatically organized, to the college-educated and to the marginally literate. “

“After a long shift at work, a Portsmouth, Va., sanitation department electrician named Andrew Culpepper picked up his toddler son from his parents, drove home, went into the house and then fell asleep, forgetting he'd had the boy in the car, leaving him to bake to death outside his home.”

“Mark Warschauer, an internationally acclaimed expert in language learning and technology, professor of education at the University of California at Irvine. Warschauer is a Fulbright scholar, specializing in the use of laptops to spread literacy to children. In the summer of 2003, he returned to his office from lunch to find a crowd surrounding a car in the parking lot. Police had smashed the window open with a crowbar. Only as he got closer did Warschauer realize it was his car. That was his first clue that he'd forgotten to drop his 10-month-old son, Mikey, at day care that morning. Mikey was dead. “

Lyn Balfour is on her cellphone, ordering a replacement strap for a bouncy seat for the new baby and simultaneously trying to arrange for an emergency sitter, because she has to get to the fertility clinic, pronto, because she just got lab results back, and she's ovulating, and her husband's in Iraq, and she wants to get artificially inseminated with his sperm, like right now, but, crap, the sitter is busy, so she grabs the kid and the keys and the diaper bag and is out the door and in the car and gone. But now the baby is fussing, so she's reaching back to give him a bottle of juice, one eye on him and the other on a seemingly endless series of hairpin turns that she negotiates adroitly. Raelyn Balfour is what is commonly called a type-A personality. She is the first to admit that her temperament contributed to the death of her son, Bryce, two years ago. It happened on March 30, 2007, the day she accidentally left the 9-month-old in the parking lot of the Charlottesville judge advocate general's office, where she worked as a transportation administrator. … The babysitter asked Balfour where Bryce was. Balfour said: "What do you mean? He's with you."

Fatal Distraction (excerpts WSJ,2009/2/27)

Fatal Distraction*What is at the heart of this issue? Our complex lifestyles, multi-tasking, rushing, and errors under stress.

*Can/should we really focus attention to reduce such behaviors in this modern society where most everyone seems to managing them successfully? (though apparently not happily!)

*Every day of our lives is played as an unseen game of Russian roulette, in which the chance of the bullet firing is imperceptibly small, but terribly catastrophic.

*Basic RC: Failures of memory, failure to look/check carefully, making a hasty action, Errors/misunderstandings in communication with others, etc.*Compounded by technology and safety legislation… makes it harder to see/notice the child if sleeping, etc. Technology solutions exist but are not popular… “The problem is simple: People think it could never happen to them.”

Chinese character ‘to forget’: losing one’s heart.Importance of staying focused on the now (not past or future)

Similar cases of Fatal Distractions• Dozing off while driving:

– USA: 100,000 police-reported crashes annually involve drowsinessand/or fatigue as a principal causal factor. Those crashes result in an estimated 1,500 fatalities and 71,000 injuries each year.

• Exxon Valdez:– Spilled approximately 10.9 million gallons of its crude oil cargo.

The oil would eventually impact over 1,100 miles of non-continuous coastline in Alaska. Largest oil spill to date in U.S. waters. RC was a combination of alcohol, poor communication, delegation, deviation from SOP.

• Friendly fire– People with dangerous weapons in dangerous, confusing (‘fog of

war’), and stressful situations. Also, weapons often fired from a distance. Casualty estimates vary by war and by data, but 10%~40% are typical.

Essentials: stay aware of hazards, act with caution, keep calm, prepare. (even for boring, repetitive, well known job; even under duress.)

Preventing: Error Categories

• Forgetting

• Delegation

• Miscommunication

• Deviation from standard ops/known methods

• Lack of verification

• Fool prone design (not fool-proofed)

• Murphy’s Law (several factors conspire)

The more the better. Take care to focus on not only what happens most frequently, but also what would be most severe if it should occur!

Preventing: Tools/Solutions

• Forgetting: Checklists, Scheduler w/ notes, Receipts

• Delegation: Expectations; Training; Escalation; Check-ups

• Miscommunication: Overlapping checks; Passdowns

• Deviations: FMEA (anticipate what can go wrong), KL/near misses, SPC, RFCs, Report bad news quickly!

• Lack of verification: Design-in checks; Set ‘mental alarms’

• Fool-prone design: Simulations; DFx; Interlock, Constraints

• Murphy’s Law: Plan 20% reserve (sched.,etc.)

The more the better. Take care to focus on not only what happens most frequently, but also what would be most severe if it should occur!

Anecdote: Nuclear Accidents

*In all cases, system design/procedures for emergency response were insufficient*In all cases, rigorous, independent oversight was considered weak*In some cases, original system design had deprioritized safety considerations

in favor of cost, schedule considerations.*In some cases, human response following trigger events, resulted in misjudgments,

thus making accident situations worse, or failed to fully contain.

EventDate/Place

Description Risk Lvl (INES)/effect TriggerSys. DesignProcess cntrl

DesignEmerg.

Org/Oversight

Equip. Human Immediate Long Term

Windscale1957/UK

Core fire5/Significant air release of Xe, Cs, I;0 deaths; Few hundred cancersexpected over time.

Annealingprocesscontrol

X X XContainment

onlyshut-down

TMI1979/USA

LOCA

5/coremeltdown; possible small H2steam explosionvery small air releases of Xe, Kr;Contaminated water release; 0deaths, 0 health effects expected.

Equip. fail in2nd loop

X X X X

Rapid siteemergency/Limited

area evac.But confusion, poor

communication.

TMI-2 shutdown;Increased system safety,man-m/c design; training,emergency checksheets,

KI pills, etc.

Chernobyl1986/USSR

Criticality

7/steam explosion, ejected fuel;Massive air release of Cs, I, Sr, Xe;31 deaths; 2 thousand of cancersexpected over time.

Experiiment X X X XEvac only after

3 days (delayed, poorcommunication)

shut-down

Fukushima2011/Japan

LOCA7(5x3) / core meltdown,H2 steam explosion; signif. Air/waterrelases of Cs ,I

Tsunami X X XRapid but disorganized

communication;Proactive evac, I-pills

(ongoing)

RC Response

My KL after Fukushima Daichi

• Low probability/High severity cases must be taken seriously

• Emergency back-up systems/plans: Reliability should not be sacrificed for cost efficiency

• High reliability systems/fool-proof designs do not preclude the necessity of having a contingency plan (“unknown-unknowns”)

• Report bad news quickly, frankly, completely

• Independent oversight is critical to ensure effectiveness of the above items.

Dealing

-Owning up (quickly!)-Apologizing-Intercultural considerations-Post mortem

Anecdote: Ehime Maru

*US nuclear sub off the coast of Hawaii, on a routine VIP showoff cruise. Did a rapid surface maneuver without fully/carefully checking radar, periscope, and other standard navy protocols. *US reaction during and immediately after the accident was viewed as callous and failing to help survivors. Subsequent responses (apologies, visits) excluded the captain for legal/official diplomatic reasons…but this made the situation even worse from Japan viewpoint.

To Add: list of errors and effects, before, during and after.

Dealing: Overview

• Prioritize containment and communication

• Just apologize. Start by admitting the part you could have done better. Demonstrate respect.

• Mimimize assumptions; Get input: Use questions to check understanding/alignment (“Seek first to understand…”)

• Be specific about containment, prevention of reoccurrence, KLs.

• Keep a record of facts, dates, names

Dealing:Intercultural

• Consult with others familiar with local culture

• Be forthright with local org. to overcome internal barriers that could impede making amends.

Recovering: the choice

• Negative:– Self-hate

– Trying to place blame and exact reparations

• Positive:– Focus on preventing future cases

(systems/design, education, etc.)

– Focus on helping others (unfortunate victims or perpetrators)

– Philanthropy/Volunteering to honor victims

Sources

• http://en.wikipedia.org/wiki/Ehime_Maru_and_USS_Greeneville_collision

• http://nobasestorieskorea.blogspot.com/2011/02/text-fwd-10th-anniversary-of-sinking-of.htmlhttp://www.asian-efl-journal.com/March_06_dl.php