Should We Manage Safety Differently?

CORPORATE SAFETY CONFERENCE

AUGUST 12, 2015

Discussion Points

Our current view of Safety

Let’s define safety differently

Talk of human error

Levels of Failure

Pre-Accident Investigation

Final Thoughts

Our Present View

The Three Parts of Every Failure

The Context The Consequence The Retrospective Understanding

1 2 3 4

Two courses of action are typically pursued

Fix the Worker (Training, Discipline, or Termination)

Fix the System (May take longer to fix, cost money)

You may recognize this….

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.

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

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

Human Error

‘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

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)

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

“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

“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

Recognize this ship?

How about a hint?

What was the failure of the Titanic?

Or

“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…

Reducing failure relies on a system focus, making integrated changes to processes and practices

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

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

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

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

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

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.