ben cook - ahspo

Empowered Accountability & Error Control AHSPO 6 August 2015

www.hse3.com.au

Copyright Convergent Performance – Human

and Systems Excellence

Zooming Out of the Mud:

Empowered Accountability &

Error Control

Ben CookCEO, Human & Systems Excellence

AHSPO, Yarra Valley Lodge

6 August 2015

Scope

Acknowledgements

Dr Tony Kern, CEO Convergent

Performance (Blue Threat IP)

The winner of multiple national and

international awards for aviation

safety and program management and

the author of six books on aviation

professionalism

http://www.convergentperformance.com/

The Four Questions

• Who is this guy…

• What qualifies him to talk to me about

my profession…

• How long is he going to talk…

• Is any of this testable?

Top Guns vs Medical Procurement?

Alan Lilly (CEO Eastern Health):

• Egos

• Strong work ethic; Can-do culture

• If you only seek good you won’t be great

• Requires disciplined people

• When it goes wrong:

• there are often lessons that were not

learnt the first time (NHS – North

Staffordshire)

http://www.convergentperformance.com/


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RoE: Participant Feedback Participant Response Clickers

Select a response:

Working – flashing green lightNot sure – orange light – press again

To select 10 press the 0/J key

CLICKER TEST: The prime minister is doing a good job?

1. 2.

69%

31%

1. Yes

2. No

I’m here today because…

1. 2. 3. 4.

58%

27%

3%

12%

1. I benefit and enjoy industry seminars

2. The boss sent me – I have to be here

3. I’m not meant to be here but I’m too embarrassed to admit it

4. I don’t know but I’m enjoying the alcohol

Years of Medical Procurement Experience?

11%

2%

13%

19%

23%

33%1. 0-5

2. 5-10

3. 10-15

4. 15-20

5. 20-25

6. 25+

With consideration to Alan Lilly’s presentation last night, the culture in my workplace is on track to support the journey from good to great?

1. 2.

45%

55%1. Yes

2. No


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Human Factors?

The minimisation of human error

and its consequences by optimising

the relationship within systems

between people, activities and

equipment

Humans remain a significant force

multiplier….

Humans remain a significant force

multiplier….

NAVY ARMY AIR FORCE

QF32

“BOOM”…”BOOM”

• 7,400ft

– Alt Hold, Hdg Sel, Thrust

– “PAN – will contact in a

few minutes”

Warning: ENG 4 OVERTHRUST PROT LOST (not displayed)


Warning: F/CTL ALTN LAW (PROT LOST)

Warning: ELEC C/B TRIPPED

Warning: ENG2 FIRE

Warning: FUEL R INR TK FWD+AFT PMPs FAULT

Warning: VENT COOLG SYS 1 OVHT

Warning: BRAKES A-SKID FAULT ON WING L/Gs

Warning: BRAKES NORM BRK PRESS MONITORING FAULT (not displayed)

Warning: BRAKES ALTN BRK PRESS MONITORING FAULT (not displayed)

Warning: L/G CTL 2 FAULT

Warning: ELEC AC BUS 2 FAULT

Warning: ELEC DRIVE 1 DISCONNECTED

Warning: AIR L INR WING LEAK

Warning: AIR ENG 2 BLEED LEAK

Warning: AIR L OUTR WING LEAK

Warning: CABIN DRAIN MASTS HEATING FAULT (not displayed)

Warning: COND FWD CARGO VENT FAULT

Warning: HYD G FUEL HEAT EXCHANGER VLV FAULT (not displayed)

Warning: FUEL JETTISON VLV NOT CLOSED

Warning: FUEL FEED TK2 : MAIN+STBY PMPs FAULT

Warning: FUEL NORM+ALTN XFR FAULT

Warning: FUEL ENG 2 LPVLV FAULT (not displayed)

Warning: FUEL L INR TK FWD+AFT PMPs FAULT

Warning: F/CTL L MID AILERON FAULT

Warning: F/CTL L OUTR AILERON FAULT

Warning: F/CTL R OUTR AILERON FAULT

Warning: HYD Y ENG 4 PMP A PRESS LO

Warning: HYD Y ENG 4 PMP B PRESS LO

Warning: HYD G RSVR AIR PRESS LO

Warning : HYD G RSVR LEVEL LO

Warning: HYD G SYS PRESS LO

Warning: ELEC DRIVE 2 DISCONNECTED

Warning: ENG 2 SHUTDOWN

Warning: ENG 1 SENSOR FAULT (not displayed)

Warning: ENG 1 NORM+ALTN MODES FAULT

Warning: ENG 2 FAIL

Warning: ENG 2 IGN A FAULT (not displayed)

Warning: ENG 4 NORM+ALTN MODES FAULT

Warning: ENG 1 FIRE LOOP A FAULT (not displayed)

Warning: ENG 2 FIRE DET FAULT

Warning: ENG 2 REVERSER MINOR FAULT (not displayed)

Warning: ENG 2 NORM MODE FAULT

Warning: ENG 2 LP SHAFT PROT LOST (not displayed)

Warning: ENG 2 FADECSYS FAULT (not displayed)


Warning: ENG 2 SLAT SYS 1+2 FAULT


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Electronic Centralised Aircraft Monitor (ECAM) Actions

130 Faults (Total)– 58 Cockpit (~ 43 displayed, Misc

Overweight Landing, )

– 38 Cabin

– 19 Pending (incl ENG 1 Master, EEC1, EEC 4, GPWS 1+2 Fault)

– 15 Minor (ADIRU 1 & 3 wiring)

87 non displayed messages (ACARS to QF)

– 13 x ice protection

– 47 x wiring harness faults

– 1 x FDAC-1 (flight data accumulator)

– 1 x SATCOM

Info– CG OUT OF LIMITS FOR LANDING

– TRANSFER TRIM TK FUEL

– TRIM TK NOT USEABLE

– TRANSFER SYS INOP

Spend more time understanding what’s working well and why.

Clone those processes!!

For example: Eastern Health (Rohan Pal)

Bright Spots?

Workplaces & Society: Global Trends?

Distractions

Workload

Serious incidents &

accidents: predictable &

preventable.

Over the past 10 years, the NTSB has investigated numerous accidents that have demonstrated time and again the danger of using portable electronic devices while operating a vehicle, plane, train, or vessel.

Talking hands-free on a cell phone led to a seasoned motor coach driver colliding with a bridge in Alexandria, Virginia, in November 2004.

Pilots overflew their destination, Minneapolis-St. Paul International Airport, by 100 miles in October 2009 because they were distracted by their laptops.

In September 2008, an engineer ignored a red signal while texting, resulting in a head-on collision near Chatsworth, California, and 25 deaths.

The use of portable electronic devices in transportation has led to an increased number of crashes and an increased number of deaths.

NTSB: Distractions


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Distractions & You?

A baby boy approaching

his first birthday died

after being left in a car

found in front of a day

care centre.

Distractions: October 2013

…the important factors that keep showing up

involve a combination of stress, emotion,

lack of sleep and change in routine…

In my workplace I believe we have a problem with unmanaged distractions leading to degraded performance and/or potential safety issues?

1. 2.

30%

70%

1. Yes

2. No

Insanity: doing the same thing over

and over again and expecting

different results.

Albert Einstein

Route Check

1

2

3

Emerging Human Performance Challenges

Blue Threat: A New Approach to Error Management

The Influence of Culture and Supervisors

4 Why Good Enough Really Isn’t


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Short Break – Stand Up & StretchThe Four Questions

• Who is this guy…

• What qualifies him to talk to me about

my profession…

• How long is he going to talk…

• Is any of this testable?

How many “Safety 101” lectures should anyone

be subjected to in their lives?

Advanced Human Factors

The Return of Personal Accountability in

the Age of System Safety


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Experts See A Different World

The purpose of this Blue Threat

curriculum is to empower each individual

to see deeper into the situation & deeper

into themselves to prevent errors and

continuously improve.

Blending Organisational

Management and Self Control Manage (mán·age) transitive verb

to oversee processes for running something

such as a store, department, or project;

to guide and control business affairs

Control (con·tról) transitive verb

to exercise power or authority over something; to

limit or restrict somebody or something in

expression, occurrence, or rate of increase

Error management needs to occur at the team and

organisational levels, but error control is personal.45

See Trouble Coming Sooner

Point of

Perception

and Detection Accident or Incident

Onset of Awareness

Time

Window of

Threat &

Opportunity

Enlarge the playing field and

time available to respond

Aggressively respond to

opportunities and threats as

they arise with new tools

Stay further ahead

of the situation

A Few New Terms and Concepts Why the Blue Threat?

The key to victory over the randomness

and variability of human error is first to

realise that error is only random in a

group setting. When you get down to a

sample size of one – you – error is both

predictable and preventable.


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Procedures

Planning, Checklists, etc.

“Key knowledge is in the work”

Person

Self Awareness, Situation

Awareness, Judgement

“Key knowledge is in the person”

Completely

RoutineTotally

Unexpected

Attention

Distraction

Information Overload

Complacency

Boredom

Span of Control

Stress Induced Error

Noncompliance

Panic

Mastery Across Every Level of Challenge

Adapted from Jensen, Csikszentmihali, Reason and Kern

Expert’s

Curse Procedures


“Key Knowledge is in the Work”

Person


Awareness, Judgment

“Key Knowledge is in the Person”

Completely

RoutineTotally

Unexpected

Attention

Distraction


Complacency

Boredom

Span of Control


NoncompliancePanic

Where is the real risk?


Risk = severity X exposure

What skills are needed to manage the

Blue Threat?What skills are needed to manage the Blue Threat?

Mature Self Assessment

Can I objectively see and accept responsibility

for my weaknesses and mistakes?

What don’t I know that I need to?

What skills don’t I have that I need?


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Habit Patterns: Distraction Control

Systems

Job Skills

Self

Management

Procedures

Our Training System:Still Vulnerable, Primed and Prone to Error

Blue Threat

Technical Training

Blue Threat Professional Development ProgramSelf Leadership – Known Competencies – Predictable Results

Peer to Peer

Accountability

Discipline

and ComplianceContinuous

Improvement

Personal

Error Control

Technical Training

Technical Training

UnknownT

ec

hn

ica

l Tra

inin

g

Te

ch

nic

al T

rain

ing

Self Leadership

Known Competencies

Predictable Results

Team Training

Team

Tra

inin

g

Team

Tra

inin

g

Team Training

Fatal Flaw in Our Thinking

It has long been assumed that when you train

someone to do something right you are

simultaneously training them not to do it wrong.

This simple premise is grossly in error and is

responsible for thousands of lost lives and billions

in lost revenue every year in high risk industries.

Seeds of Complacency We also assume since we have never

had an accident or incident, our current

behaviors are safe – even if its not the

best we can do or we do not precisely

conform to all policies or procedures.

Fact: Things that have never happened

before, happen all the time.


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Continuous

updating of

procedures

to avoid

recurrence

of past

accidents

and

incidents

History

of system

Scope of

regulated

action

Actions sometimes

necessary to get the job done

Source. Human Error. Reason. 1990

Good policy and procedures are organizationalcornerstones.

Compliance is an individual cornerstone.

Red Rules, Green Rules and

Brown Rules

“Follow the rules

or change them,

there is no other

good choice.”

Guidance

Policy Norms

Operational Performance

Results

Procedures Techniques

DiscretionaryMandatory

When Cultural Norms Trump Policy

Purpose

“Go” Fight

Source. Blue Threat. Kern. 2010

“Slow” Fight

Regulation

Government

Equipment Manual

Standards Authority

Standard Workplace Procedures

Organisation/Company

Department

Safety Management System

Self-Discipline

You

Without Personal Professional Discipline, Safety

Management Systems Disintegrate from Within

Copyright Kern, Ryan and Agostino, 2005

Conventional Wisdom on Human Error

“People will always make mistakes, that’s a given.”

“It’s easier to change situations than people.”

“To err is human . . . it is easier to manage error than to

prevent it.”

“Human error mishaps are just the cost of doing

business.”

“We are forced to work with the crooked timber of

human fallibility.”

“Serious human factors experts moved beyond the

individual error approach 20 years ago.”

“The weakest link in the cockpit is wearing a headset.”

Blue Threat Proverb #29

“Only human” is the ultimate oxymoron.


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So What?

I disagree with the conventional wisdom on error.

I believe that human error is not inevitable nor “part

of being human” any more than cancer is.

Errors do happen, but most can be controlled with

little more than enhanced knowledge and serious

personal intent.

Cancer Death Rates* by Sex, 1975-2005

Source: US Mortality Data 1960-2005, National Centre for Health Statistics, Centres for Disease Control and

Prevention, 2008.

0

50

100

150

200

250

300

1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005

Men

Both Sexes

Rate Per 100,000

Women

How was this trend

reversed with an

ageing population?

We learned what was

causing it and did a

few things differently.

Close Fight

M

i

s

h

a

p

R

a

t

e

Time

Engineering, Technology, Tools

and Equipment

Safety Systems, Processes

and Procedures, Team

Training

Safety Culture

Personal

Behaviours

“The challenge of human

error will never be

remedied by any traditional

training or safety program.

Personal error must be

slowly untangled – in a

private battle within each

individual.

Blue Threat, Tony Kern, 2010

This is true because in high achievers, human error

and personal weakness is secret and sacred ground;

at least until the accident investigators and lawyers

show up after the fall.”

Short Break – Stand Up & Stretch

Wrap up: Why “Good Enough”

Really Isn’tEmpowered Accountability Through

Continuous Improvement

The Next Generation of Human Factors


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Blue Threat Levels of Effort and Competency

As little as you want – as much as you need.

My current level of Blue Threat competence?

10%

16%

26%

25%

18%

4%

1. Level 1 – Uninformed Status Quo

2. Level 2 - Awareness

3. Level 3 - Process

4. Level 4 - Analysis

5. Level 5 - Procedures

6. Level 6 - Habit

Accident

Incident

Violation

Hazard

Fatality

Safety

Effectiveness

Efficiency

Precision

Perfection

“Good Enough”

The crushing grip

of mediocrity

Performance Evolution Ladder – Copyright 1998 T. Kern

True safety, quality and

sustainability live here

Survival

Reaching for precision – Will it be there?

There are times when precision is

required; when “good enough” isn’t

anymore.

Maybe only 1 time in 1000, or even

1 in 10,000 but you don’t get to

choose the time of reckoning.

Why should we expect to perform

under extreme conditions at levels

we do not practice for on a daily

basis?

Accident

Incident

Violation

Hazard

Fatality

Safety

Effectiveness

Efficiency

Precision

Survival

Perfection

Performance Evolution Ladder – Copyright 1998 T. Kern

Accuracy without precision is

usually good enough to earn a

salary, but not always good

enough to survive

A perfect

day?

New Optics

When viewed through the enlightened

eyes of individuals, the vast majority of

“random errors” are predictable.

Predictable is preventable.


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Critical Incident Technique

(Flanagan, Andersson, others)

Human Error Assessment and Reduction Technique

(modified)

(HEART)

Williams, J. T.; FAA Human Factors Workbench

Violation Producing Conditions

(Hawkins, Maurino, Reason, Kern, others)

Hazardous Attitudes

(FAA, Helmreich, others)

Cognitive Bias(Cortes, Crosskerry, others)

Situational Factors

Group Induced Errors

(various)

Risk Mgt(US Army, USAF, USN, USMC,

others)

The “expert’s curse” includes ______

1. Span of control, distraction, panic

2. Apathy, distraction, loss of SA

3. Complacency, non compliance, boredom

4. All of the above

1. 2. 3. 4.

4%

50%

45%

1%

Procedures


“Key knowledge is in the work”

Person


Awareness, Judgement

“Key knowledge is in the person”

Completely

RoutineTotally

Unexpected

Attention

Distraction


Complacency

Boredom

Span of Control


Noncompliance

Panic

Mastery Across Every Level of Challenge


Expert’s

Curse

Summary and Takeaways?

• New tools (self management) to enhance individual & team performance

• Return on investment – empowered & focused (home and work)

• Maintain & enhance professionalism even when confronted by poor workplace culture &/or the experts curse

• If not you - next generations need it more than ever!!!

What does good to great really look like? Presentation Critique


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Ben was clear and easy to understand?

NAVY ARMY AIR FORCE

0%

1%

0%

2%

41%

56%1. Strongly agree

2. Agree

3. Slightly agree

4. Slightly disagree

5. Disagree

6. Strongly disagree

97%

Ben demonstrated thorough knowledge of the topic area?

NAVY ARMY AIR FORCE

0%

0%

1%

5%

39%


2. Agree

3. Slightly agree


5. Disagree


94%

Ben engaged the audience and held attention easily?

NAVY ARMY AIR FORCE

0%

0%

2%

3%

27%


2. Agree

3. Slightly agree


5. Disagree


94%

The information was relevant?

NAVY ARMY AIR FORCE

1%

1%

2%

12%

45%


2. Agree

3. Slightly agree


5. Disagree


84%

10: Very positive, excellent information and learning experience

5: Just over the line but could be much better

1: Very negative, poor information not relevant

The Scoring System (out of 10)With consideration to the presentation

Clicker - To select 10 press the 0/J key (bottom, middle)

Overall Presentation Score?

A. 1.B. 2.C. 3.D. 4.E. 5.F. 6.G. 7.H. 8.I. 9.J. 10.

1. 2. 3. 4. 5. 6. 7. 8. 9.10.

2% 2%

0%1%

39%

24%

18%

11%

1%1%

81%


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Further Support

Ben Cook

[email protected]

0403 536 552

www.hse3.com.au

ben cook - ahspo

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