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Factors contributing to incident causation
Corporate Governance
loose cultureconflicting objectives
unclear expectations
unclear priorities
focus on commercial targets
uncontrolled change management
inadequate control of business processes
condone non-compliance
lack of consequent management
scorecard driven
not open for ‘bad’ news
focus on slips, trips & falls (TRCF)focus on cost reduction
Immediate causes at sharp end
human error
equipment failureno intervention
Incidentlack of hazard awarenessacceptance of high risks
poor communication and hand-over
non-compliance
Organisation & systems
inadequate standards & procedures
lack of competence
lack of resources poor audits and reviews
inadequate design
maintenance back-log
time pressure
workloadinadequate HEMP process
Inadequate monitoring & corrective action
lack of supervisionunclear roles & responsibilities inadequate ER system production pressure
Pushing operating window
Human Behavior
Unintended action
Intended action
SlipViolation LapseMistake
“I forgot to
indicate”
“I used the windscreen
wiper”
“I took the wrong turn”
Basic Error Types
“I jumped the light”
Human errors and violations
Not An Error
The need for rules
Many hazards cannot be controlled by hardware or designOther hazards are more easily controlled by administrative approachesThere are three levels of specification
Guidelines – “Ought to”Descriptions and sequences – “Should”Work instructions – “Must”
Failure to follow procedures temporarily negates the control of the management system
The assumption is that all the rules will be followed
The Simple (Old) View -How to manage non-compliance
Rules and procedures are there for a purposePersonnel are expected to know them and are clearly expected to comply with all relevant proceduresFailures to comply represent a deliberate failure of an individual’s performance contractSuch failures cannot be tolerated, because the SMS relies upon complianceNon-compliance is best managed by making people aware of the personal consequences, from written warnings to dismissal
Review of the Simple ViewThere is an assumption that all rules and procedures are optimal and not in need of improvement
The US Nuclear INPO studies found that 60% of procedural problems were due to incorrect procedures
The requirement is for unquestioning compliance by a worker
The INPO studies found that most people did follow procedures, even when they were incorrect
A weaker version of such requirements may require challenge
This is often based upon following the incorrect rule or procedure first, with subsequent challenge
The Just Culture - Version 2Empirical studies of non-compliance showed a complex picture6 different types of violationManagers and supervisors have a role as well as the violating workerIndividuals will be working with a variety of intentions, from the company’s interest to their personal gainSolutions range from improving the system to ensuring compliance
Types of Violation
• Unintended• Knowledge and understanding• Avaliability
• Situational• Optimizing
• Personal benefit• Organizational benefit
• Exceptional
• Routine is a multiplier on the different types (excluding exceptional)
Individual causes of accidents
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Immediate Causes - Error Types
0% 10% 20% 30% 40% 50%
Slip
Lapse
Mistake
Non-Compliance
Circumstances
Technical (Non-Human factor)
Environment (non-human factor)
EPDS
EP = Upstream DS = Downstream
Underlying causes of accidents
14
Underlying causes - Error types
0% 10% 20% 30% 40% 50% 60%
Slip
Lapse
Mistake
Non-compliance
Cultural
Technical (Non-Human factor)
Environment (non-human factor)
EPDS
EP = Upstream DS = Downstream
A Just and Fair Culture version 3Did they followall procedures
andbest practices?
Did they thinkthey were following
the proceduresand practices?
Everyone doesIt this way round
here.Don’t you know?
We can’t followthe procedure andget the job done
I thought it wasbetter for the
Company to dothe job that way
I thought it wasbetter for mepersonally tocut a corner
Screw you.I meant to do it
my way
Oh dearDid we do that!?
Normal Compliance
Routine violation
Situational violation
Optimizing violation
Personal optimizing violation
Reckless personal
optimization
Exceptional violation
Unintentional violation
Awareness/ Understanding
Man
agem
ent
Supe
rvis
ion
Des
crip
tion
Wor
kfor
ceD
isci
plin
eCo
achi
ngVi
olat
ion
type
Feel comfortable,But be aware, thisMay be unusual
Did we not expectsuch situations
to arise?HSE-MS problem?
Set standards.Examine proceduresThis may be a real
improvement
How did we hireSuch a person?
Set standardsExamine hiring &
retentionpolicies
Why didn’t peoplerealise this was a
Problem?
Take active stepsto identify this sort of violation
Use MRB
Get very active.How were poor
proceduressigned off?
Praise the worker
Did we trainpeople in how toreact in unusual circumstances?
Why is this notbeing recognised?
Use MRBAllow variances
How did we let him stay here?Didn’t we know
In advance?
Set standardsRecognise that
Such people areIn workforce
Investigate and apply MRB
Investigate and apply MRB
Investigate. Must listen to
workforcecomplaints
Feel satisfiedDid I check withsupervisor and
colleagues?
Report possibility,Raise before work
Acquire competenceLeave Company
Decide whetherYou wish towork here
Report if theydiscover they have
violated aprocedure
Get involved infinding out if the
procedure isnecessary
Must report allsuch impossible
situations
None
Did they followall procedures
andbest practices?
Blame everyonefor not playing
their part
Summarydismissal
Warning letterto worker
No blame forworker
Active coaching ofall, at all levels forcondoning routine
violation
Blame everyonefor not playing
their part
Praise the workerUse as an example
For others
Did they followall procedures
andbest practices?
Coach people totell (workers)
andlisten (managers &
supervisors)
Coach managers& supervisors
to recognise &deal with such
individuals
Coach managersand supervisors
on settingstandards
Management needto examine the
quality of procedure system
Everyone use MRBto see if rulenecessary, or
ensure compliance
Coach people totell (workers)
andlisten (managers &
supervisors)
Why Replace “Just Culture”with another model?
Application can drive undesirable behaviour e.g A fatality investigation highlighted previous use of “Just Culture” as a contributory factorThe old model appears to assume individual guilt unless proven otherwiseThe drawing, (from left to right), implies visually where priorities lie. The amount of space devoted to discipline does the sameApplication of framework is not seen as ‘Just’ – often called “7 ways to sack yourself”The old model focuses mostly on the person at the “sharp end” and does not take into account the role of the manager/supervisor in creating the environment which led to the action
Why is the new model better?
This is a just and fair model because it recognises safety behaviour as well as non-complianceIt recognises that managers and supervisors have a role as well as the violating worker.The model looks at everyone's role in the incident.
It builds on the psychology of understanding different types of violation and their causesIt recognises that individuals will be working with a variety of intentions, from the company’s interest to their personal gain
Meets visual requirements for priorities
Accountability
• The model helps define accountabilities, and consequences for success and failure at all levels
• Workforce individuals have specific roles only they can play
• Supervisors play a vital role between top and bottom
• Managers have responsibilities, identifiable in terms of accountabilities, that everyone else relies on
Conclusion
• It is possible to identify what people should do• This needs to be placed in a clear and public process• Success creates two of the pillars of an advanced
culture of safety• Trust• Accountability
Human Error and Violation Decision Flowchart
Was there a behaviour
below expectation?
Was something
done not the way
originally intended to do it or was a procedural
step forgotten?
Did the person make an incorrect decision or
was their work plan
inadequate?
Did the person
violate a rule or procedure because they
were unaware of the rule or
did not understand
it?
Did the person
violate a rule or procedure because they believed the job couldn’t
be done if they followed
the procedures?
Did they violate a rule or procedure
thinking it was better
for the company to
do it that way? Or,
were they trying to
please their boss?
Did the person
violating think it was
better for them
personally to do it that
way?
Did the person violating mean
to do what they did and did not think
or care about the
consequences?
ERRORS ORGANIZATIONAL ISSUES PERSONAL ISSUES
Slip or Lapse Mistake Unintentional violation
SituationalViolation
Organizational
optimizingviolation
Personaloptimizingviolation
RecklessViolation
Has this happened before?
Routine Error
Personal history of errors
Routine Error
Same errors by different people
Routine Violation
Others do it like that
Routine Violation
Personal history of violation
Do other people behave in the same way? Does this person have a history of personal
violations?
yes yes yes yes yes yes
yes no
yes
no no no no
Sheep and Wolves
The North Sea study found 2 dimensionsSheep’s clothing - Wolves’ clothing
Your ‘clothing’ shows if you have violated recently Sheep - Wolves
Sheep don’t like to violate, wolves don’t mindSheep are the Guardians of High StandardsWolves are go-getting opportunistsWolves are Natural Born Violators
Why are Violations so Dangerous?Violators assume everyone else is following the rules and proceduresViolations are forbidden, so violators don’t tell anyone what they are doingViolations take the system out to the EdgeViolations destroy a main assumption of the SMSErrors (slips, lapses, mistakes) are independent of intentionViolation + Error = Death/Doom/Disaster
Why do People violate?Behaviours are caused by intentions turned into plans of actionBehaviours are a response to the recognition of an opportunityPoor planning makes violation a solution to a problemIf nothing has improved since last time, people will expect to violate again
An Alternative Model:Supervision and Punishment
An alternative model, what many managers think will workSupervise by watching harder over peoplePunish whenever people are caught
Behavioural Cause model explained 64.2%Supervise and Punish explained 20%Combining both models explained 67.0%Added value from 64.2% to 67.0%
Attribution errors, judgment and honesty
• The fundamental attribution error• Different in cultures individualism – collectivism• Different for pilots and surgeons
• Hindsight bias – knew it all along
• The just world and punishment• Bad things happen to bad people
Challenge the future
DelftUniversity ofTechnology
The Lethal CocktailThe Main Predictors
Powerfulness
Opportunities
Planning
Expectation Expectation that rules will have to be bent to get the work done
The feeling that one has the ability and experience to do the job without slavishly
following the procedures
Seeing opportunities that present themselves for short cuts or to do things
‘better’
Inadequate work planning and advance preparation, leading to working ‘on the fly’
and solving problems as they arise
Mindful
Informed
Reporting
Just
Flexible,Learning
risk managementand continuous improvement happen here
Six Key Characteristics of a ’Highly Reliable’ Safety Cultu
The HSSE Culture Ladder & SMS
CALCULATIVEWe have systems in place to
manage all hazards
PROACTIVESafety leadership and values drive
continuous improvement
REACTIVESafety is important, we do a lotevery time we have an accident
PATHOLOGICALWho cares as long as
we're not caught
GENERATIVE (High Reliability Orgs)HSE is how we do business
round here
In Place
In Operation
Effective
Permanent
Implementation lessons learned
• Get everyone on board first• Unions, managers, senior managers• The managers have to agree to be put in the firing line
• Involve Human Resources from the start• They consider training and real consequences to be their
territory• Agree a process of evaluation
• Start quarterly joint evaluations with all parties• Reduce frequency with success and acceptance to annually
• The negative side is much easier than the positive
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