The New View of Safety – Building Defenses and Capacity

Jim Howe, CSP, Safety Solutions, jimhowe@earthlink.net March 20, 2014

Health and Safety

Performance Incident Rate =

Talking ourselves over the cliff!

Is it recordable or lost time?

Actual Consequences

Potential Consequences

British Petroleum, Deep Water Horizon Gulf of Mexico

April 20, 2010 The entire oil drilling rig burned and sank.

11 workers died.

Executives were on the rig the morning of the incident to celebrate seven years without a lost time injury.

What is safety?

Safety is the absence of injuries and illnesses.

Safety is the presence of defenses.

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During the past six years, longshore workers have suffered a fatality rate of 17.3 deaths per 100,000 employees, compared to 16.6 deaths for firefighters and 14.9 deaths for police officers. ILWU Dispatcher, May 2008

The New View of Safety – Building

Defenses and Capacity

Organization Chart

Sharp End

Blunt End

Workers

Supervisors

Managers

Department Heads

Executives

Organization Chart Facility Level

| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

16 March 24, 2014

Front Line (Sharp end of the stick)

Sharp End

Blunt End

Workers

Department Heads

Supervisors

Executives

Managers

Old View New View System View

Active Trigger Latent Conditions

Leadership concept #1 Characteristic of High Reliability Organizations Reluctant to accept "simple" explanations for problems.

When Things Go Wrong How It Is Now . . . You are highly trained and If you did as trained, you would not make mistakes so You weren’t careful enough so You should be PUNISHED!

How It Should Be . . . You are human and Humans make mistakes so Let’s also explore why the system allowed, or failed to accommodate, your mistake so Let’s IMPROVE THE SYSTEM!

Chris Hart, Vice Chair, NTSB, Collaboration: Improving Safety in Complex Industries

Before

Without a Systems View After

Hazard Risk

Normal Work

Safety Understood: How work actually gets done.

Todd Conklin

Work as imagined How those at the blunt end of the stick think the job is done

Start Of

Job

Normally Successful!

Outcome bias Event

Context: Learning

Input Process Output

Continual Change

Sharp End

Blunt End

Workers

Department Heads

Supervisors

Executives

Managers

Workers Are As Safe As They Think They Need To Be,

In Order To Get The Jobs Done.

Without Being Overly Safe…

Todd Conklin

Workers are highly skilled in adapting their work to respond to ever changing situations in real time in

order to be safe and get the job done in an efficient

manner.

Critical leadership question How an organization responds to failure.

DOE STANDARD , HUMAN PERFORMANCE IMPROVEMENT HANDBOOK VOLUME 1: CONCEPTS AND PRINCIPLES, page 131

DOE STANDARD , HUMAN PERFORMANCE IMPROVEMENT HANDBOOK VOLUME 1: CONCEPTS AND PRINCIPLES, page 131

Injuries Illnesses

Near misses Occurrences

Latent conditions

Organizational Culture

Culture eats management systems for breakfast!

http://regnet.anu.edu.au/sites/default/files/WorkingPaper_69.pdf

Three Parts of an Event

Consequence Retrospective understanding

?

Todd Conklin

Hindsight Is always 20/20

Hindsight Knowledge of the outcome

Investigators know the outcome.

Those at the sharp end of the stick didn’t know the outcome.

What could have been done? Why did it make sense to them to do what they did?

Children playing at school in Atlanta

Children running from explosion in Baghdad Iraq

Students from Sandy Hook Elementary School after their Super Bowl performance

What’s the story? Data alone has no meaning; it takes context to make sense

Context

Those at the sharp end of the stick.

Context

Ask “how” instead of “why”

Clearly Safe to do Work

Clearly Not Safe to do Work

Old View of Safety

Workers Discover Safety…

Clearly Safe to do Work

Clearly Not Safe to do Work

Uncertain interpretation of Safe work

• short cut • work around

What’s the difference between a

• process improvement?

What will it take?

One final question

The worker failed the system…

The system failed the worker…

or

Thank You!