Human Performance and Learning – The Next Steps

1. Human Performanceand Learning – The Next Steps Brownfields 2013 Ron Snyder, HMTRI/CCCHST Adapted from: Todd Conklin PhD Los Alamos National Laboratory

2. Never Take a Sleeping Pill and a Laxative at the Same Time.

3. Never Remove A Safety Barrier That Has A Dent In It.

4. The Fastest Way To Improve Safety In Your Organization… Change the Way Your Organization Responds to Failure.

5. Safety is not the absence of accidents. Safety is the presence of defenses.

6. Safety is the ability to perform work in a varying and unpredictable work environment.

7. Start Of Job Mission Success Work as Planned

8. Here’s what we know… • Planned work is normally more successful than unplanned work • All plans are great until we begin to use them • Planning assumes perfection – perfection is a terrible operational performance standard Planned Work

9. People Are As Safe As They Need To Be, WithoutBeing Overly Safe…In Order To Get Their Job Done.

10. Or Are They..

12. “ To understand failure…we must first understand our reaction to failure.” “People do not operate in a vacuum, where they can decide and act all-powerfully. To err or not to err is not a choice. Instead, people’s work is subject to and constrained by multiple factors.” — Sidney Dekker Human Performance

13. Things that never happened before… Happen all the time. Karl Weick

14. Worker’s Don’t Cause Failures. Worker’s Trigger Latent Conditions That Lie Dormant In Organizations Waiting for This Specific Moment In Time.

15. “Accidents are the unexpected combination of normal performance variability” Eric Hollnagel Failure Defined…

16. Accidents Happen Because: • What is about to happen is simply not possible. • What is about to happen has no perceived connection to what is currently happening. • The possibility of getting the intended outcome is well worth whatever risk there is. Accidents Don’t Happen Because Workers Gamble and Lose…

17. Start Of Job Mission Success Work as Done

18. Your Workers Are Masters of Complex Adaptive Behavior…

19. Clearly Safe to do Work Clearly Not Safe to do Work The Grey Area: Uncertain interpretation of Safe work Why Stop Work is easier to say than to do… Unclassified

20. Human Error Expertise Identification Exercise

21. How many times does the uppercase or lowercase letter“F”appear in the following sentence? Finished files are the re- sult of years of scientific study combined with the experience of many years. Finished files are the re- sult of years of scientific study combined with the experience of many years.

22. “Mistakes arise directly from the way the mind handles information, not through stupidity or carelessness.” -Edward de Bono PhD Limitations of Human Nature

23. “Knowledge and error flow from the same mental sources, only success can tell one from the other.” Ernst Mach, 1905

24. Events aren’t predictable, But the environment in which Events are most likely to happen is…

25. Choose and number between 1 and 10 • Multiply that number by 9 • Add the two digits of this number together • Subtract 5 from this new number • Translate this number to a letter – 1 = A, 2 = B… • With this letter – choose a country that starts with that selected letter • With the last letter of this country – choose an animal • With the last letter of this animal – choose a fruit

26. Denmark Kangaroo Orange

27. “The problem with the future is that more bad things can happen than will happen.” -Plato

28. Start Of Job Event Hazard Accumulation of Risk

29. Where will the next safety event be in your organization? • What can we do today to prevent this event. Predictability

30. The human performance in question usually involves a set of interacting people.

31. Risk

32. “Risk that you can control are much less a source of outrage than risks you can NOT control.” -Peter Sandman, PhD Risk

33. Western-Economic View • Bias View • Cultural View • All Represent an interactive phenomenon Risk Perceptions

34. The context in which events happen plays a major role in human performance.

35. Old View New View Human error is a symptom of trouble deeper inside a system To explain failure, do not try to find out where people went wrong Instead, find out how peoples’ actions and assessments made sense at the time given the circumstances that surrounded them. • Human error is a cause of accidents • To explain failure, investigations must seek failures of parts of systems • These investigations must find inaccurate assessments and bad decisions How We See Events

36. Systems Thinking Is About Relationships… Not About The Individual Parts of the Failure.

37. Complex systems have a strong tendency to move incrementally toward unsafe operations Human errors become more complex when systems become more complex With increased complexity, more unanticipated situations exist More encounters in which procedures are non-optimal or non-workable Process Complexity Unclassified

38. Human errors become more complex More unanticipated situations exist More encounters in which procedures are not optimal (work-arounds) or non-workable situations As systems become more complex Unclassified

39. Achieve success or Avoid failure Purpose of Procedures? Unclassified

40. In highly complex processes – there will be more errors (because of the complexity of the process) – However, highly complex processes have much less tolerance for error. The Complexity Conundrum Unclassified

41. Workplaces and organizations are easier to manage than the minds of individual workers. You cannot change the human condition, but you can change the conditions under which people work. — Dr. James Reason Organizational Processes Unclassified

42. Event Prevention Happens Through Learning.

43. Normal Work Start Of Job Risk Understanding: Learning Event Hazard Accumulation of Risk

44. Error without consequence is a good thing… It shows that our systems are error-tolerant and that they are working.

45. The attribution of error-after-the-fact is a process of social judgment rather than an objective conclusion.

46. When investigating a Failure - Organizations ultimately “dumb” all worker decisions down to two choices: To Screw Up To Not Screw Up

47. Deviation from Expected Behavior Error The Gray Area “Intentional Variation” Violation Potential Learning Target Area Traditional View of Error and Violation

48. Are the people ok? • Is the facility safe and stable? • Tell me the story of what happened? • What could have happened? • What factors led up to this event? • What worked well? What failed? • Where else could this problem happen? • What else should I know? 8 Questions A Manager Should Ask

49. Constantly fixate on the next failure. • Work hard to reduce operational complexity. • Respond seriously to pre-cursor information. • Respond deliberately to actual events. Organizations that do this well do 4 things:

50. Safety is not the absence of accidents. Safety is the presence of defenses.