Todd Conklin PhD Sr. Safety Advisor Los Alamos National Labs [email protected] The Curious...

Todd Conklin PhD

Sr. Safety Advisor

Los Alamos National Labs

[email protected]

Human Performance

TheCuriousOrganization

Royce Railey

Regional S&H Manager

Cintas Corporation

Never take a sleeping pillAnd a laxativeAt the same time…

…In any order

Conklin/Railey


Safety is not the absence of Accidents.

Safety is the presence of

defenses.TheCuriousOrganization Conklin/Railey

People Are As Safe As They Need To Be,

Without Being Overly Safe…

In Order To Get Their

Job Done.

TheCuriousOrganization Conklin/Railey

*Human Performance

“ To understand failure…we must first understand our reaction to failure.”

— Sidney Dekker


Workers Don’t Cause Failures.

Worker’s Trigger Latent Conditions That Lie Dormant In OrganizationsWaiting for This Specific Moment In Time.

Conklin/Railey


Ask HowNot Why!

Conklin/Railey

*Human Performance

We Must ManageWorker Behavior and Work ProcessesIn Parallel…


9

*Principles ofHuman Performance

1.People are fallible

2.Error-likely situations are predictable

3.Individual behaviors are influenced

4.Operational upsets can be avoided

5.Management’s response to failure matters


*People are fallible, and even

the best make mistakes.

Human Performance Principle 1:

Conklin/Railey

HumanError

ExpertiseIdentification

Exercise


12

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


Error is not a choice.

Mistakes

Violations=


WorkersAre Masters ofComplex AdaptiveBehavior… The

CuriousOrganizationConklin/Railey

Unclassified16

*Workers FIND Safety at Work…

Clearly Safeto do Work

Clearly Not Safeto do Work

The Gray Area:Uncertain

interpretationof Safe work


Unclassified17

* After the Event, Safety is Clear…

Clearly Safeto do Work

Clearly Not Safeto do WorkEvent


Accidents happen when workers find themselves in situations where it is easy to get hurt and

hard to be safe.


*Error-likely situations are

predictable, manageable, and

preventable.



Events aren’t predictable,But the environment in whichEvents may happen is…


*Predictability

Where will the next safety event happen at your site?

Conklin/Railey

The story of all the little events….

Collectively tell the STORY of where the next event may happen.

ConklinConklin/Railey

*Management’s response to failure matters.



24

*Work as Imagined Vs. Work in Practice

NormallySuccessful!


Drift and Accumulation

Solution Space

The Power of EarlyHazardID

Identifiedor Discovered

Problem


Solution Space

Identifiedor Discovered

Problem

The Power of EarlyHazardID


*Origins of Human Error

10%

90%30%

70%

Human Error

Slip, trip or lapse

Equipment Failures

Human Errors

Operational Upsets

System Induced Error

Conklin/Railey


*Old vs. New View of Human Error

*Human error is a cause of accidents…

*To explain failure, investigations must seek failure

*They must find people’s inaccurate assessments, wrong decisions and bad judgments

*Human error is a symptom of trouble deeper inside a system…

*To explain failure, do not try to find where people went wrong.

*Instead, find how people’s assessments and actions made sense at the time, given the circumstances that surrounded them.

OLD

NEW

Make it easy to See problems

Swarm and Fix problems.

Spread new knowledge.

Lead by developing this capacity.

*Stephen Spear, The High Velocity Edge

The Challenge…


Safety is not the absence of Accidents.

Safety is the presence of

defenses.TheCuriousOrganization Conklin/Railey

Todd Conklin PhD Sr. Safety Advisor Los Alamos National Labs [email protected] The Curious...

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