oh those human error safety incidents
TRANSCRIPT
OH those Human ErrorSafety Incidents
When you Investigate the Cause was it the worker or the plan that failed?
TO Error is HUMAN
TYPES
Safety's Three Major Concerns
When you have incidentsdo you check?
When you do inspection do you consider
Do you think about worker maturity and culture?
Part of the Scope
Who knows what and why
Does the WHOLE TEAMknow the values listed
Does the team help or hinder in these questions
Your Risk Values to the investigation
Does the team look at
Common is to everyone
Who talked to WHOM and When
Leadership
A Simple Model
Performance outcome Y is a
function of factors X.
PerformanceOutcome
Factors AffectingOutcome Y
Y = f (x)
Why a Human Performance Improvement
Approach?
80% Human
Error30%
Individ
ual
20%
Equipment
Failures
Human Error
Unwanted
Outcomes70%
Latent
Organiza
tion
Weaknes
ses
Facts about Human Error
• It thrives in every industry
• It is a major contributor to events and unwanted outcomes
• It is costly, adverse to safety and hinders productivity
• The greatest cause of human error is weaknesses in the organization, not lack of skill or knowledge
• Error rates can never be reduced to zero
• Consequences of errors can be eliminated
Principles
1. People are fallible, and even the best make
mistakes.
2. Error-likely situations are predictable,
manageable, and preventable.
3. Individual behavior is influenced by
organizational processes and values.
4. People achieve high levels of performance
based largely on the encouragement and
reinforcement received from leaders, peers,
and subordinates.
5. Events can be avoided by understanding
the reasons mistakes occur and
applying the lessons learned from past
events.
Plant
Worker
Processes Values
Individual
• Limited short-term memory• Personality conflicts
• Mental shortcuts (biases)• Lack of alternative indication
• Inaccurate risk perception (Pollyanna)• Unexpected equipment conditions
• Mindset (“tuned” to see)• Hidden system response
• Complacency / Overconfidence• Workarounds / OOS instruments
• Assumptions (inaccurate mental picture)
• Confusing displays or controls
• Habit patterns• Changes / Departures from routine
• Stress (limits attention)• Distractions / Interruptions
Human NatureWork Environment
• Illness / Fatigue• Lack of or unclear standards
• “Hazardous” attitude for critical task• Unclear goals, roles, & responsibilities
• Indistinct problem-solving skills• Interpretation requirements
• Lack of proficiency / Inexperience• Irrecoverable acts
• Imprecise communication habits• Repetitive actions, monotonous
• New technique not used before• Simultaneous, multiple tasks
• Lack of knowledge (mental model)• High Workload (memory requirements)
• Unfamiliarity w/ task / First time• Time pressure (in a hurry)
Individual CapabilitiesTask Demands
Error Precursorsshort list
Limitations of Human Nature
Avoidance of mental strain
Inaccurate mental models
Limited working memory
Limited attentionresources
Pollyanna effect
Mind set
Difficulty seeing own errors
Limited perspective
Susceptible to emotion
Focus on goal
Human Information Processing
Shared
Attention
Resources
ThinkingSensing Acting
Information
Flow Path
Performance Modes--Attending Problems
Familiarity (w/ task)Low High
High
Low
Att
en
tio
n (
to t
ask)
Inattention
Misinterpretation
Inaccurate
Mental Picture
Blame
Cycle
Human
Error
Less
communication
Management less
aware of jobsite
conditions
Reduced trustLatent organizational
weaknesses persist
Individual counseled
and/or disciplined
More flawed defenses
& error precursors
The Blame Cycle
Human Performance Tools
• Critical Steps
• Enhanced Pre-Job Briefing
• Peer Check
• Self Check
• Independent Verification
• Error Traps
• Just Culture
• Effective Communication
• Questioning Attitude
• Feeling of Uneasiness
• Enhanced Turnover
• 3 way communication
• Error Precursors
• Performance/Error Modes
• Devils Advocate
• Place keeping
• Poka Yoke
• SAFE Dialogue
• Discovery Clock
• STAR
• Training
Yes it really is part of your plan and so are you
Me, Bob and You!
Create the right culture
• Instead, companies should try to create a culture of openness around the reporting of incidents, and identify in advance certain divisions or groups of employees where errors are more likely to occur. Even then companies can still be seriously affected by people making mistakes, brought about by a change in personnel, regulation that affects workplace protocols, or even by an error occurring within the supply chain or among contractors.