pre accident investigation.pdf
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Todd Conklin PhDHuman Performance Improvement
High Reliability
Toddconklin@gmail.com
Pre Accident
Investigation
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Never
take a sleeping pillAnd a laxative
at the same time.
In any order
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Safety is not
the absence offailures.
Safety is the
presence ofdefenses.
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ConklinConklin
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Until Theyre NOT
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*
To understand
f ilurewe must first
understand our
reaction to failure
Sidney Dekker
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3 Parts of an Event
Conklin
Pre-Accident Investigations Conklin 2012
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*
Conklin
We Must Manage
Behaviorand
Work ProcessesIn Parallel
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Workers arePeople
Workers are
not Machines.Conklin
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Workers Dont
Cause
Failures.
Workers
Trigger
Latent
Conditions That Lie
Dormant In Organizations
Waiting for This Specific
Moment In Time.
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People
MakeMistakes(All the time)
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Human
ErrorExpertise
IdentificationExercise
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13
How many times does the uppercaseor lowercase letterFappear in
the following sentence?
Finished files are the re-sult of years of scientific
study combined with the
experience of many years.
Finished files are the re-sult ofyears ofscientific
study combined with the
experience ofmany years.
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Mistakes arise directly from
the way the mind handlesinformation, not through
stupidity or carelessness.
-Edward de Bono PhD
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Error is not a choice.
Mistakes
Violations
=
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Make it easyto talk aboutconditions
that are wrong
Conklin
1
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Shift your
thinking from
Why
to HowConklin
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Workers fail when
they find themselvesin situations where it
is easy to get hurtand hard to be safe.
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A reliable
organization can
spot an actiongoing wrongnot
Wait for an action
gone wrong.
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Start
Of
Job
Hazard
Event
Normal
WorkPre-
Accident
Learning:
Safety Understood:
Drift and Accumulation
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Workers
Are Masters ofComplex Adaptive
BehaviorConklin
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*
Clearly Safe
to do Work
Clearly Not Safe
to do Work
The Gray Area:
Uncertaininterpretation
of Safe work
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*
Clearly Safe
to do Work
Clearly Not Safe
to do Work
Event
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Atten
tionTo
T
ask
Familiarity With Task
Automatic
Hi
Hi
If - Then
Patterns
1/10,000
Inattention
1/1000Misinterpretation
1/2
Mental Picture
Performance Modes
Conklin
Translated from Jens RasmussenHuman Errors: A Taxonomy for Describing
Human Malfunction in Industrial Instillations
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Swarm
in the right
people
Learn and FixConklin
2
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Knowing less
Does not make
You smarter.or safer.
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All Eventpreventionhappens through
Learning
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You cannot
Learn andPerform at theSame Time.
The Problem
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The story of
all the littleevents.
Collectively
tells you
where the
next eventmay happen.Conklin
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Conklin
If you want to know
how work is done
Ask a worker.
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Conklin
When you investigate an event
and the workers is notinvolvedYoure talking
about the worker.When the worker is involved
your talking with the worker.
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Is thejuiceworth the
squeeze?Conklin
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Behavioris theproduct of yourOrganizational
System
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1. Choose and number between 1 and 10
2. Multiply that number by 9
3. Add the two digits of this number together
4. Subtract 5 from this new number
5. Translate this number to a letter 1 = A, 2 = B
6. With this letter choose a country that starts withthat selected letter
7. With the last letter of this country choose ananimal
8. With the last letter of this animal choose a fruit
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Denmark
Kangaroo
Orange
Th P f
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Solution Space
The Power of
Early
HazardID
Identified
or Discovered
Problem
Conklin
Th P
f
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Solution SpaceThe Power of
Early
HazardID
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Learn
beforeActing
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1. Make it easy to see
conditions that are wrong.2. Swarm in and Learn and
Fix.
3. Spread the news across theSite.
4. Leave the capacity for thepeople to do it again
themselves.
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Safety is not the
absence offailures.
Safety is the
presence ofdefenses.
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Safety is thefreedom fromunacceptable
risk.
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