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Todd ConklinPreAccident Podcast
HumanPerformance
Highly Reliable Organizations
Todd Conklin PhDHuman Performance Improvement/ [email protected]
Never take a sleeping pillAnd a laxative at the same time.
In any order…
Conklin
The Safety Journey So Far…
Time
Acc
iden
tsCompliance• Behaviors• Policy/Rules• Enforcement
Design• Human Factors• Process Safety• Standardized
Systems Human Performance• New View• Not Individual• Organizational
issues Identified
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FatalitySerious Event• Not like others• NO near misses• Exist in success• Understand work
TraditionalSafety
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1. Workers are the problem to be fixed. We fix safety by making workers better.
2. We must tell workers what to do and, perhaps more importantly, not to do.
3. Safety is the absence of accidents.
SafetyDifferently
1. Workers are not the problem – They are the problem solvers.
2. We don’t tell our organizations what to do – ask them what they need.
3. Safety is not the absence of accidents – it is the presence of capacity.
Safety is not the absence of Accidents.
Safety is the presence of
Defenses.Conklin
Capacity.
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Workers are as safe as they need to be,
Without being too safe,
in order to be
productive.
Until They’re NOT..
Sharp End
Blunt End
Workers
Managers
Front-lineSupervisors
Leaders
CustomersRegulators
Company
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HighestInfluence
OverSystem
HighestInjury
Potential
Our work is
notinherently safe.
People create safety in practice.
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Parts of an EventConklin
Pre-Accident Investigations, Conklin 2013
3
Worker’s Don’t CauseFailures.
Worker’s Trigger Latent Conditions That Lie Dormant In OrganizationsWaiting for This Specific Moment In Time.
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Shift your thinking from “Who Failed” to “What Failed”
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We must stop seeing
workers as problems to be fixed.
But, as Solutionsto be harnessed.
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WorkersAre Masters ofComplex AdaptiveBehavior…
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HOTDOG
*
Clearly Safeto do Work
Clearly Not Safeto do Work
The Gray Area:Uncertain
interpretationof Safe work
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20
*
Clearly Safeto do Work
Clearly Not Safeto do WorkEvent
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StartOf
Job
Hazard
Safety Understood:Drift and Accumulation
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Work ExecutionImprovement
Area
System Safety:Fatality Prevention
Area
Is the juiceworth the squeeze?
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Capacity
The Power of EarlyHazardID
Identifiedor Discovered
Problem
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CapacityThe Power of EarlyHazardID
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Its pretty simple…You can
Blame & PunishOr
Learn & Improve.
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Safety is not the absence of Accidents.
Safety is the presence of
Capacity.Conklin
Todd ConklinPreAccident Podcast