pre accident investigation.pdf

8/9/2019 Pre accident investigation.pdf

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Todd Conklin PhDHuman Performance Improvement

High Reliability

[email protected]

Pre Accident

Investigation

Conklin


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Never

take a sleeping pillAnd a laxative

at the same time.

In any order

Conklin


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Safety is not

the absence offailures.

Safety is the

presence ofdefenses.

Conklin


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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)

Conklin


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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.

Conklin


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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

=

Conklin


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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.

Conklin


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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

Conklin


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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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23

*

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

Conklin


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You cannot

Learn andPerform at theSame Time.

The Problem

Conklin


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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.

Conklin


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Safety is not the

absence offailures.

Safety is the

presence ofdefenses.

Conklin


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Safety is thefreedom fromunacceptable

risk.

Conklin


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