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Should We Manage Safety Differently?
CORPORATE SAFETY CONFERENCE
AUGUST 12, 2015
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Discussion Points
Our current view of Safety
Let’s define safety differently
Talk of human error
Levels of Failure
Pre-Accident Investigation
Final Thoughts
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Our Present View
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The Three Parts of Every Failure
The Context The Consequence The Retrospective Understanding
1 2 3 4
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Two courses of action are typically pursued
Fix the Worker (Training, Discipline, or Termination)
Fix the System (May take longer to fix, cost money)
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You may recognize this….
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Measurement focuses on incidents
Successful Safety Program
Absence of Accidents
LTIR TCIR DART
Near Misses
We count the people we hurt, and totally discount all the employees we are keeping safe.
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We must change the way we manage safety or order to align our organizations and operations to a new definition of what “safe” is, and why it matters
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It begins with how we define “Safety”
Traditional Approach
Let’s Change our Definition
The state of being safe; freedom from the occurrence or risk of injury, danger, or loss
Safety is not the absence of events, Safety is the presence of defenses
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Human Error
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‘People Make Errors’
Errors are noticed if there is some type of outcome or consequence that is significant enough to be noticed
Errors are simply the unintentional deviation from an expected behavior
They occur everywhere, and there is nothing you can do to avoid them
It is how people are wired, how we are made, a natural part of being human
You can’t punish away errors, and you can’t reward it away either
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Systemic Issues Cause Human Error
We need to understand why it made sense for them to do what they did
Explore and identify symptoms of trouble deeper inside the system
Address the gaps between how work is imagined (in rules) and how it is done (in practice)
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What can we learn from the auto industry
How many fatal highway accidents occur per year on average?A. 5,000
B. 10,000
C. 20,000
D. 30,000
Answer….30,000
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“Change everything but the driver”
Tire pressure monitoring
Adaptive Cruise Control/collision mitigation
Blind spot detection/side assist
Lane departure warning
Rollover prevention/mitigation
Occupant –sensitive/ dual stage airbags
Emergency brake assist / collision mitigation
Adaptive headlights an/or night vision assist
Rearview camera
Emergency response
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“Let’s fix the worker!”
In many instances, we try to get safety performance by “leaving everything the
same except fixing the employee”
We rarely fix the system around the employee
No one person has the power to stop all accidents in the workplace
We must build systems to allow workers to fail safer. Start thinking like the car
industry
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Recognize this ship?
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How about a hint?
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What was the failure of the Titanic?
Or
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“The Practically Unsinkable Ship”
1. Traveling through known iceberg area
2. Watertight bulkheads – that weren’t exactly watertight
3. Crows Nest (Lookout) – did not have binoculars
4. Crew had a total of 6-hours of sea trials
5. Some exits were locked to keep the lower class passengers below deck
6. Fitted with only 20 lifeboats (3 different types)
7. Iceberg report given to Capt. Smith
8. Marconi wireless radio – used to transmit passenger messages
9. Distress Calls
…..so the story and failure of the Titanic was more than an iceberg, or captain
Let’s review the multilayered failures…
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Reducing failure relies on a system focus, making integrated changes to processes and practices
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Identifying Pre-Accidents
Tasks you know will cause consequences if these
process fail
Looking at the process and saying :when this process fails what safety defenses
will reduce and control the consequences
We must assume failure will happen
Look for high consequence activities
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Identifying Pre-Accidents
Errors, near misses, close calls – any of these factors
could indicate problems
Monitor low level events – systems that can be
confusing, conflicting, or flawed
Small events allow us to take the “pulse” of our processes
and systems
Look for small signals that can indicate system weaknesses within the normal work process
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Identifying Pre-Accidents
Look for cases where if the worker were to follow the process, the worker would
fail
Where we place workers in positions of uncertainty, while we assume there is
clarity
Review job instructions, training, JHA’s
Look for error provoking system steps and processes
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Identifying Pre-Accidents
Ask your employees where the next accident will happen – you’ll be surprised to what
you learn
Your employees know where your system makes sense, works well, and is efficient
Don’t defend the process over the opinion of the
employee
Listen to your employees
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Identifying Pre-Accidents
You’re not ever going to be able to stop an accident – but we can change how it affects the organization
Pre-accident investigations help us be better prepared
for failure
The only tool you have to prevent events from
happening is your organizations ability to learn
Engage and strengthen your system against potential failures
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Final Thoughts….
1. Be fixated on where the next failure will happen – Like all good organizations. Good companies don’t want to be surprised
2. Strive to reduce complicated operations – Ask ourselves if this operational complication make work easier to do? Or is this complicated system serving some part of the organization other than the worker?
3. Respond to low level signals seriously – We collect near miss and close call information, let’s make sure we act. They are a function of how much our workers trust us and our organizations
4. Respond to events deliberately - Don’t get emotional, don’t go out and fix the worker, don’t enact immediate policy and rule change. Slow down and learn.
5. Change how we measure safety – Focus on looking for the presence of positive capacities in people, teams, and organization.