際際滷

際際滷Share a Scribd company logo

16 Muschara NERC 3-27-13.pdf

J
jcintpa

The document summarizes a presentation on managing human performance (Hu) risk given by Tony Muschara, CPT, at a human performance conference in Atlanta, Georgia from March 26-28, 2013. The presentation discusses adopting a strategic, risk-based approach to safety by anticipating errors, monitoring risks, responding appropriately, and learning from experiences. It emphasizes that systems govern results and outlines tools and practices for controlling human risk at critical steps to reduce error rates and maintain a chronic sense of uneasiness about failure.

1 of 28
Download to read offline
Human Performance Conference Atlanta, Georgia, March 26-28, 2013 Strategic Approach to Managing Strategic Approach to Managing g pp g g g pp g g Human Performance (Hu) Risk Human Performance (Hu) Risk Tony Muschara, CPT Tony Muschara, CPT The Certified Performance Technologist (CPT) designation is awarded by the The Certified Performance Technologist (CPT) designation is awarded by the International Society for Performance Improvement (ISPI) to experienced International Society for Performance Improvement (ISPI) to experienced practitioners in the field of organizational performance improvement whose work practitioners in the field of organizational performance improvement whose work meets both the performance meets both the performance- -based Standards of Performance Technology and based Standards of Performance Technology and application requirements. For more information, visit www.certifiedpt.org application requirements. For more information, visit www.certifiedpt.org Copyright Copyright Muschara Error Management Consulting, Muschara Error Management Consulting, LLC LLC
Strategic Approach: Risk Strategic Approach: Risk- -Based* Based* Safety is what you Safety is what you DO DO to ensure the to ensure the integrity of integrity of assets assets: : integrity of integrity of assets assets: : 1. 1. Control Control: at : at Critical Critical Steps StepsSM SM Dr. James Reason Dr. James Reason 2. 2. Learn Learn: Land Mines and : Land Mines and Latent System Weaknesses Latent System Weaknesses Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC Latent System Weaknesses Latent System Weaknesses 2 *Woods, D. et al. (2010), *Woods, D. et al. (2010), Behind Human Error Behind Human Error (2 (2nd nd ed.), Ashgate, pp.38 ed.), Ashgate, pp.38- -39, 244 39, 244- -246 246
is good enough most of the time is good enough most of the time is good enough most of the time. is good enough most of the time. Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 3
Lets Align Our Beliefs* Lets Align Our Beliefs* 1 1 To err is human To err is human 1. 1. To err is human. To err is human. 2. 2. To drift is human. To drift is human. 3. 3. Risk is everywhere and dynamic. Risk is everywhere and dynamic. 4. 4. Safety is a value and adaptive. Safety is a value and adaptive. 5 5 Systems govern results Systems govern results 5. 5. Systems govern results. Systems govern results. Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 4 * Adapted from Marx, David (2005), Cultural Change and Effective Safety Management. Transport Canada: PowerPoint. May 200 * Adapted from Marx, David (2005), Cultural Change and Effective Safety Management. Transport Canada: PowerPoint. May 2005. 5. http http://www.tc.gc.ca/media/documents/ac ://www.tc.gc.ca/media/documents/ac- -normes/marx.pdf normes/marx.pdf
To Err is Human To Err is Human 3 3 to to 4 4 3 3 to to errors errors per per hour* hour* Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 5 * Source: Dr. Michael * Source: Dr. Michael Frese Frese (2008), (2008), Learning Learning from Errors by Individuals from Errors by Individuals and Organizations. Invited Talk at and Organizations. Invited Talk at Association of Psychological Science (APS) Conference, May 28, 2008. Association of Psychological Science (APS) Conference, May 28, 2008.
Video: To Drift is Human Video: To Drift is Human Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 6
Video: Risk is Dynamic Video: Risk is Dynamic Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 7
Safety is a Value* Safety is a Value* Safety is Safety is NOT NOT the the y y absence of accidents. absence of accidents. S f t i th S f t i th f d f i f d f i Safety is the Safety is the presence presence of defenses in of defenses in your processes, procedures, facilities, your processes, procedures, facilities, methods, and practices. methods, and practices. Safety is what you Safety is what you DO DO to ensure to ensure Safety is what you Safety is what you DO DO to ensure to ensure the integrity of the integrity of assets assets using a variety using a variety f l b i d f d f l b i d f d Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC of controls, barriers, and safeguards of controls, barriers, and safeguards 8 *Woods, D. et al. (2010), *Woods, D. et al. (2010), Behind Human Error Behind Human Error (2 (2nd nd ed.), Ashgate, pp.38 ed.), Ashgate, pp.38- -39, 244 39, 244- -246. 246.
System Accidents: Systems Govern Results* System Accidents: Systems Govern Results* L L Defenses (LOP) Defenses (LOP) Losses Losses (assets) (assets) Land Mines Land Mines Land Mines Active Active Error Error Error Traps: (conditions people work in that tend to provoke error) Latent System Weaknesses: Management Systems | Processes | Plans H d | D i | L d hi | C lt Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC Hardware | Design | Leadership | Culture 9 * Adapted from Reason, J. (1998), * Adapted from Reason, J. (1998), Managing the Risks of Organizational Accidents; Managing the Risks of Organizational Accidents; p.16 p.16- -18. 18.
Video: Fall Through Floor Video: Fall Through Floor Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 10
Touching = Risk Touching = Risk Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 11
TouchPoint TouchPoint A A human human interaction interaction with an asset that with an asset that changes changes the the state state of that asset through of that asset through work work Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 12 Initiates a transfer Initiates a transfer of energy, mass, or of energy, mass, or information information
Risk Risk- -Based Practices* Based Practices* A AM MR RL L A Anticipate nticipate know know what to expect what to expect M M it it k k h t t tt ti t h t t tt ti t M Monitor onitor know know what to pay attention to what to pay attention to R Respond espond know know what to do what to do L Learn earn know know: : what has happened what has happened what has happened what has happened what is happening what is happening what to change what to change what to change what to change Touching = Risk Touching = Risk Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC * * Adapted from Adapted from Hollnagel, et al., Hollnagel, et al., Resilience Engineering Resilience Engineering, (2006), p.350, and , (2006), p.350, and Resilience Engineering Perspectives, Vol. 2 Resilience Engineering Perspectives, Vol. 2, (2009), pp.117 , (2009), pp.117- -133. 133. Touching Risk Touching Risk 13
Operations: Work Operations: Work Execution Process Execution Process Assets (work output) ( p ) C CRITICAL RITICAL S STEP TEPSM SM Positive Control! Positive Control! Learning Execution (work behavior) Error Preparation Land Error Traps Land Mines Real-time Performance: Sharp End Organization Organization: Blunt End Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC Organization 14 .99100
If 99% was Good Enough If 99% was Good Enough Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 15
Trolltunga Trolltunga Odd Odd N N Odda Odda, Norway , Norway Is 99.9% good Is 99.9% good g g enough here? enough here? Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 16
C CRITICAL RITICAL S STEP TEP SM SM Point of No Return Point of No Return | | What What MUST MUST Go Right Go Right Single Single- -Error Error Vulnerability Vulnerability Point of No Return Point of No Return | | What What MUST MUST Go Right Go Right Any human action that Any human action that will will trigger trigger immediate immediate, , irreversible, intolerable irreversible, intolerable harm harm to an asset (if that action or a to an asset (if that action or a ( ( preceding action is performed improperly) preceding action is performed improperly) A AM MR RL L A AM MR RL L Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 17
Hu Tools Hu Tools 1. 1. Pre Pre- -Job Briefing Job Briefing 2 2 Take a Minute Take a Minute 2. 2. Take a Minute Take a Minute 3. 3. Self Self- -Checking (STAR) Checking (STAR) S Wh U S Wh U Carving out Carving out time to think time to think 4. 4. Stop When Unsure Stop When Unsure 5. 5. Peer Peer- -Checking Checking time to think time to think 6. 6. Three Three- -Part communication Part communication 7. 7. Procedure Use & Adherence Procedure Use & Adherence | | | | Placekeeping Placekeeping 8. 8. Conservative Decision Conservative Decision- -Making Making Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC g g 9. 9. After Action Review After Action Review | | Reporting Reporting 18
RU RU- -SAFE SAFE: : Pre Pre- -Job Briefing Job Briefing 1. 1.Review Review Task Task Purpose / Accomplishments. Purpose / Accomplishments. 2 2 Id tif Id tif A t( ) t A t( ) t P t t P t t 2. 2.Identify Identify Asset(s) to Asset(s) to Protect: Protect: R Recognize ecognize assets to assets to protect and related hazards protect and related hazards U Understand nderstand lessons learned from experience lessons learned from experience p p S Summarize ummarize critical steps and related risk critical steps and related risk- -important important actions actions A Anticipate nticipate errors traps and errors for each critical errors traps and errors for each critical A Anticipate nticipate errors traps and errors for each critical errors traps and errors for each critical step step F Foresee oresee consequences of errors consequences of errors at each critical step at each critical step E Evaluate valuate Hu Tools, Hu Tools, defenses, contingencies defenses, contingencies, and , and STOP work criteria STOP work criteria 3. 3.State State End of End of Briefing. Briefing. Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 19 3. 3.State State End of End of Briefing. Briefing.
Error Rate Reduction Error Rate Reduction ate Before ror Ra Hu Tools Er After Randomness Time Randomness Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 20
Video: Highline Walker Video: Highline Walker Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 21
Chronic Sense of Uneasiness* Chronic Sense of Uneasiness* A Preoccupation with Failure A Preoccupation with Failure A Preoccupation with Failure A Preoccupation with Failure M Mindfulness indfulness M Mindfulness indfulness toward toward assets assets: : 1 1) ) ones capacity to ones capacity to A AM MR RL L ) ) p y p y err, i.e., err, i.e., error traps error traps 2) 2) the presence of the presence of hidd th t hidd th t A AM MR RL L hidden threats, hidden threats, i.e., i.e., land mines land mines how you perceive, think, and feel about assets and their hazards What else can I What else can I do do to rise above my circumstances to rise above my circumstances to get the to get the results results I desire I desire? ? Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC * * Reason, J. (2008), Reason, J. (2008), The Human Contribution The Human Contribution, p.274. , p.274. g g -- -- The Oz Principle The Oz Principle 22
Workers Role Workers Role Control Control 1. 1. Acknowledge human fallibility ( Acknowledge human fallibility (hazard hazard). ). 2 2 Know and understand the Know and understand the technology technology 2. 2. Know and understand the Know and understand the technology technology. . 3. 3. Know the Know the assets assets to protect to protect the Business. the Business. 4 4 K K C C S S SM SM P iti C t l! P iti C t l! 4. 4. Know Know C CRITICAL RITICAL S STEPS TEPSSM SM Positive Control! Positive Control! 5. 5. Be wary of error traps and land mines. Be wary of error traps and land mines. 6. 6. Stop when Unsure Stop when Unsure Get the Facts! Get the Facts! 7. 7. Avoid unsafe and at Avoid unsafe and at- -risk practices. risk practices. 8. 8. Ask for and give feedback Ask for and give feedback Dont know what Dont know what 9. 9. Report Report Dont live with problems! Dont live with problems! Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 10. 10. Prove it Safe Prove it Safe practice practice A AM MR RL L ( (hero hero). ). 23
Managing Drift and Accumulation* Managing Drift and Accumulation* Hi Expectations: Work as Imagined Normal Practice: Work as Done Drift Drift ety ety Hi Expectations Expectations Normal Normal Error Error Safe Safe Normal Normal Practice Practice Real Real Margin for Error Margin for Error Mgmt Mgmt Accumulation Accumulation anger anger Risk Mgmt Accumulation Accumulation Inconspicuous and seemingly harmless buildup of unusual conditions, hazards, threats, at-risk priorities, etc., without warning Da Da Lo Hidden Hidden Conditions: hazards, Conditions: hazards, threats threats, , unusual conditions unusual conditions, & , & land mines land mines Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC Lo Time * Adapted from Dekker, S. (2007), * Adapted from Dekker, S. (2007), The Field Guide to Understanding Human Error The Field Guide to Understanding Human Error. . 24
Managers Role Managers Role Learn Learn 1. 1. Manage Manage integrate integrate A AM MR RL L into systems; into systems; align around align around proactive proactive accountability* (assets) accountability* (assets) align around align around proactive proactive accountability (assets) accountability (assets) 2. 2. Lead Lead inculcate inculcate key key beliefs beliefs into the into the culture; create reinforcing experiences culture; create reinforcing experiences culture; create reinforcing experiences culture; create reinforcing experiences 3. 3. Organizational Organizational minimize minimize accumulation accumulation f LSW / l d i i t it f d f f LSW / l d i i t it f d f of LSWs / land mines; integrity of defenses of LSWs / land mines; integrity of defenses 4. 4. Operational Operational control control: avoid : avoid active errors active errors t t iti l t i i i d ift iti l t i i i d ift at at c critical steps; minimize drift ritical steps; minimize drift 5. 5. Oversight Oversight monitor monitor: eliminate gaps : eliminate gaps Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC between between work as imagined work as imagined and and work as done work as done 25 * * Connors, R. et al. (2004). Connors, R. et al. (2004). The Oz Principle The Oz Principle. p.47. . p.47.
Managing H Managing Hu u Y t Y t You cannot You cannot manage manage what you do what you do not not understand understand. . y y -- -- Elliot Elliot Jacques, Jacques, Th Th R i it O i ti R i it O i ti The The Requisite Organization Requisite Organization Human performance is not common sense. Human performance is not common sense. Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 26
Strategic Approach* Strategic Approach* Safety is what you Safety is what you DO DO to ensure the to ensure the integrity of integrity of assets assets: : integrity of integrity of assets assets: : 1. 1. Control Control: at : at Critical Critical Steps StepsSM SM 2. 2. Learn Learn: Land Mines and : Land Mines and Latent System Weaknesses Latent System Weaknesses Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC Latent System Weaknesses Latent System Weaknesses 27 *Woods, D. et al. (2010), *Woods, D. et al. (2010), Behind Human Error Behind Human Error (2 (2nd nd ed.), Ashgate, pp.38 ed.), Ashgate, pp.38- -39, 244 39, 244- -246 246
The Passion The Passion Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 28

More Related Content

16 Muschara NERC 3-27-13.pdf

  • 1. Human Performance Conference Atlanta, Georgia, March 26-28, 2013 Strategic Approach to Managing Strategic Approach to Managing g pp g g g pp g g Human Performance (Hu) Risk Human Performance (Hu) Risk Tony Muschara, CPT Tony Muschara, CPT The Certified Performance Technologist (CPT) designation is awarded by the The Certified Performance Technologist (CPT) designation is awarded by the International Society for Performance Improvement (ISPI) to experienced International Society for Performance Improvement (ISPI) to experienced practitioners in the field of organizational performance improvement whose work practitioners in the field of organizational performance improvement whose work meets both the performance meets both the performance- -based Standards of Performance Technology and based Standards of Performance Technology and application requirements. For more information, visit www.certifiedpt.org application requirements. For more information, visit www.certifiedpt.org Copyright Copyright Muschara Error Management Consulting, Muschara Error Management Consulting, LLC LLC
  • 2. Strategic Approach: Risk Strategic Approach: Risk- -Based* Based* Safety is what you Safety is what you DO DO to ensure the to ensure the integrity of integrity of assets assets: : integrity of integrity of assets assets: : 1. 1. Control Control: at : at Critical Critical Steps StepsSM SM Dr. James Reason Dr. James Reason 2. 2. Learn Learn: Land Mines and : Land Mines and Latent System Weaknesses Latent System Weaknesses Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC Latent System Weaknesses Latent System Weaknesses 2 *Woods, D. et al. (2010), *Woods, D. et al. (2010), Behind Human Error Behind Human Error (2 (2nd nd ed.), Ashgate, pp.38 ed.), Ashgate, pp.38- -39, 244 39, 244- -246 246
  • 3. is good enough most of the time is good enough most of the time is good enough most of the time. is good enough most of the time. Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 3
  • 4. Lets Align Our Beliefs* Lets Align Our Beliefs* 1 1 To err is human To err is human 1. 1. To err is human. To err is human. 2. 2. To drift is human. To drift is human. 3. 3. Risk is everywhere and dynamic. Risk is everywhere and dynamic. 4. 4. Safety is a value and adaptive. Safety is a value and adaptive. 5 5 Systems govern results Systems govern results 5. 5. Systems govern results. Systems govern results. Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 4 * Adapted from Marx, David (2005), Cultural Change and Effective Safety Management. Transport Canada: PowerPoint. May 200 * Adapted from Marx, David (2005), Cultural Change and Effective Safety Management. Transport Canada: PowerPoint. May 2005. 5. http http://www.tc.gc.ca/media/documents/ac ://www.tc.gc.ca/media/documents/ac- -normes/marx.pdf normes/marx.pdf
  • 5. To Err is Human To Err is Human 3 3 to to 4 4 3 3 to to errors errors per per hour* hour* Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 5 * Source: Dr. Michael * Source: Dr. Michael Frese Frese (2008), (2008), Learning Learning from Errors by Individuals from Errors by Individuals and Organizations. Invited Talk at and Organizations. Invited Talk at Association of Psychological Science (APS) Conference, May 28, 2008. Association of Psychological Science (APS) Conference, May 28, 2008.
  • 6. Video: To Drift is Human Video: To Drift is Human Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 6
  • 7. Video: Risk is Dynamic Video: Risk is Dynamic Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 7
  • 8. Safety is a Value* Safety is a Value* Safety is Safety is NOT NOT the the y y absence of accidents. absence of accidents. S f t i th S f t i th f d f i f d f i Safety is the Safety is the presence presence of defenses in of defenses in your processes, procedures, facilities, your processes, procedures, facilities, methods, and practices. methods, and practices. Safety is what you Safety is what you DO DO to ensure to ensure Safety is what you Safety is what you DO DO to ensure to ensure the integrity of the integrity of assets assets using a variety using a variety f l b i d f d f l b i d f d Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC of controls, barriers, and safeguards of controls, barriers, and safeguards 8 *Woods, D. et al. (2010), *Woods, D. et al. (2010), Behind Human Error Behind Human Error (2 (2nd nd ed.), Ashgate, pp.38 ed.), Ashgate, pp.38- -39, 244 39, 244- -246. 246.
  • 9. System Accidents: Systems Govern Results* System Accidents: Systems Govern Results* L L Defenses (LOP) Defenses (LOP) Losses Losses (assets) (assets) Land Mines Land Mines Land Mines Active Active Error Error Error Traps: (conditions people work in that tend to provoke error) Latent System Weaknesses: Management Systems | Processes | Plans H d | D i | L d hi | C lt Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC Hardware | Design | Leadership | Culture 9 * Adapted from Reason, J. (1998), * Adapted from Reason, J. (1998), Managing the Risks of Organizational Accidents; Managing the Risks of Organizational Accidents; p.16 p.16- -18. 18.
  • 10. Video: Fall Through Floor Video: Fall Through Floor Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 10
  • 11. Touching = Risk Touching = Risk Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 11
  • 12. TouchPoint TouchPoint A A human human interaction interaction with an asset that with an asset that changes changes the the state state of that asset through of that asset through work work Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 12 Initiates a transfer Initiates a transfer of energy, mass, or of energy, mass, or information information
  • 13. Risk Risk- -Based Practices* Based Practices* A AM MR RL L A Anticipate nticipate know know what to expect what to expect M M it it k k h t t tt ti t h t t tt ti t M Monitor onitor know know what to pay attention to what to pay attention to R Respond espond know know what to do what to do L Learn earn know know: : what has happened what has happened what has happened what has happened what is happening what is happening what to change what to change what to change what to change Touching = Risk Touching = Risk Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC * * Adapted from Adapted from Hollnagel, et al., Hollnagel, et al., Resilience Engineering Resilience Engineering, (2006), p.350, and , (2006), p.350, and Resilience Engineering Perspectives, Vol. 2 Resilience Engineering Perspectives, Vol. 2, (2009), pp.117 , (2009), pp.117- -133. 133. Touching Risk Touching Risk 13
  • 14. Operations: Work Operations: Work Execution Process Execution Process Assets (work output) ( p ) C CRITICAL RITICAL S STEP TEPSM SM Positive Control! Positive Control! Learning Execution (work behavior) Error Preparation Land Error Traps Land Mines Real-time Performance: Sharp End Organization Organization: Blunt End Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC Organization 14 .99100
  • 15. If 99% was Good Enough If 99% was Good Enough Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 15
  • 16. Trolltunga Trolltunga Odd Odd N N Odda Odda, Norway , Norway Is 99.9% good Is 99.9% good g g enough here? enough here? Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 16
  • 17. C CRITICAL RITICAL S STEP TEP SM SM Point of No Return Point of No Return | | What What MUST MUST Go Right Go Right Single Single- -Error Error Vulnerability Vulnerability Point of No Return Point of No Return | | What What MUST MUST Go Right Go Right Any human action that Any human action that will will trigger trigger immediate immediate, , irreversible, intolerable irreversible, intolerable harm harm to an asset (if that action or a to an asset (if that action or a ( ( preceding action is performed improperly) preceding action is performed improperly) A AM MR RL L A AM MR RL L Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 17
  • 18. Hu Tools Hu Tools 1. 1. Pre Pre- -Job Briefing Job Briefing 2 2 Take a Minute Take a Minute 2. 2. Take a Minute Take a Minute 3. 3. Self Self- -Checking (STAR) Checking (STAR) S Wh U S Wh U Carving out Carving out time to think time to think 4. 4. Stop When Unsure Stop When Unsure 5. 5. Peer Peer- -Checking Checking time to think time to think 6. 6. Three Three- -Part communication Part communication 7. 7. Procedure Use & Adherence Procedure Use & Adherence | | | | Placekeeping Placekeeping 8. 8. Conservative Decision Conservative Decision- -Making Making Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC g g 9. 9. After Action Review After Action Review | | Reporting Reporting 18
  • 19. RU RU- -SAFE SAFE: : Pre Pre- -Job Briefing Job Briefing 1. 1.Review Review Task Task Purpose / Accomplishments. Purpose / Accomplishments. 2 2 Id tif Id tif A t( ) t A t( ) t P t t P t t 2. 2.Identify Identify Asset(s) to Asset(s) to Protect: Protect: R Recognize ecognize assets to assets to protect and related hazards protect and related hazards U Understand nderstand lessons learned from experience lessons learned from experience p p S Summarize ummarize critical steps and related risk critical steps and related risk- -important important actions actions A Anticipate nticipate errors traps and errors for each critical errors traps and errors for each critical A Anticipate nticipate errors traps and errors for each critical errors traps and errors for each critical step step F Foresee oresee consequences of errors consequences of errors at each critical step at each critical step E Evaluate valuate Hu Tools, Hu Tools, defenses, contingencies defenses, contingencies, and , and STOP work criteria STOP work criteria 3. 3.State State End of End of Briefing. Briefing. Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 19 3. 3.State State End of End of Briefing. Briefing.
  • 20. Error Rate Reduction Error Rate Reduction ate Before ror Ra Hu Tools Er After Randomness Time Randomness Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 20
  • 21. Video: Highline Walker Video: Highline Walker Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 21
  • 22. Chronic Sense of Uneasiness* Chronic Sense of Uneasiness* A Preoccupation with Failure A Preoccupation with Failure A Preoccupation with Failure A Preoccupation with Failure M Mindfulness indfulness M Mindfulness indfulness toward toward assets assets: : 1 1) ) ones capacity to ones capacity to A AM MR RL L ) ) p y p y err, i.e., err, i.e., error traps error traps 2) 2) the presence of the presence of hidd th t hidd th t A AM MR RL L hidden threats, hidden threats, i.e., i.e., land mines land mines how you perceive, think, and feel about assets and their hazards What else can I What else can I do do to rise above my circumstances to rise above my circumstances to get the to get the results results I desire I desire? ? Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC * * Reason, J. (2008), Reason, J. (2008), The Human Contribution The Human Contribution, p.274. , p.274. g g -- -- The Oz Principle The Oz Principle 22
  • 23. Workers Role Workers Role Control Control 1. 1. Acknowledge human fallibility ( Acknowledge human fallibility (hazard hazard). ). 2 2 Know and understand the Know and understand the technology technology 2. 2. Know and understand the Know and understand the technology technology. . 3. 3. Know the Know the assets assets to protect to protect the Business. the Business. 4 4 K K C C S S SM SM P iti C t l! P iti C t l! 4. 4. Know Know C CRITICAL RITICAL S STEPS TEPSSM SM Positive Control! Positive Control! 5. 5. Be wary of error traps and land mines. Be wary of error traps and land mines. 6. 6. Stop when Unsure Stop when Unsure Get the Facts! Get the Facts! 7. 7. Avoid unsafe and at Avoid unsafe and at- -risk practices. risk practices. 8. 8. Ask for and give feedback Ask for and give feedback Dont know what Dont know what 9. 9. Report Report Dont live with problems! Dont live with problems! Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 10. 10. Prove it Safe Prove it Safe practice practice A AM MR RL L ( (hero hero). ). 23
  • 24. Managing Drift and Accumulation* Managing Drift and Accumulation* Hi Expectations: Work as Imagined Normal Practice: Work as Done Drift Drift ety ety Hi Expectations Expectations Normal Normal Error Error Safe Safe Normal Normal Practice Practice Real Real Margin for Error Margin for Error Mgmt Mgmt Accumulation Accumulation anger anger Risk Mgmt Accumulation Accumulation Inconspicuous and seemingly harmless buildup of unusual conditions, hazards, threats, at-risk priorities, etc., without warning Da Da Lo Hidden Hidden Conditions: hazards, Conditions: hazards, threats threats, , unusual conditions unusual conditions, & , & land mines land mines Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC Lo Time * Adapted from Dekker, S. (2007), * Adapted from Dekker, S. (2007), The Field Guide to Understanding Human Error The Field Guide to Understanding Human Error. . 24
  • 25. Managers Role Managers Role Learn Learn 1. 1. Manage Manage integrate integrate A AM MR RL L into systems; into systems; align around align around proactive proactive accountability* (assets) accountability* (assets) align around align around proactive proactive accountability (assets) accountability (assets) 2. 2. Lead Lead inculcate inculcate key key beliefs beliefs into the into the culture; create reinforcing experiences culture; create reinforcing experiences culture; create reinforcing experiences culture; create reinforcing experiences 3. 3. Organizational Organizational minimize minimize accumulation accumulation f LSW / l d i i t it f d f f LSW / l d i i t it f d f of LSWs / land mines; integrity of defenses of LSWs / land mines; integrity of defenses 4. 4. Operational Operational control control: avoid : avoid active errors active errors t t iti l t i i i d ift iti l t i i i d ift at at c critical steps; minimize drift ritical steps; minimize drift 5. 5. Oversight Oversight monitor monitor: eliminate gaps : eliminate gaps Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC between between work as imagined work as imagined and and work as done work as done 25 * * Connors, R. et al. (2004). Connors, R. et al. (2004). The Oz Principle The Oz Principle. p.47. . p.47.
  • 26. Managing H Managing Hu u Y t Y t You cannot You cannot manage manage what you do what you do not not understand understand. . y y -- -- Elliot Elliot Jacques, Jacques, Th Th R i it O i ti R i it O i ti The The Requisite Organization Requisite Organization Human performance is not common sense. Human performance is not common sense. Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 26
  • 27. Strategic Approach* Strategic Approach* Safety is what you Safety is what you DO DO to ensure the to ensure the integrity of integrity of assets assets: : integrity of integrity of assets assets: : 1. 1. Control Control: at : at Critical Critical Steps StepsSM SM 2. 2. Learn Learn: Land Mines and : Land Mines and Latent System Weaknesses Latent System Weaknesses Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC Latent System Weaknesses Latent System Weaknesses 27 *Woods, D. et al. (2010), *Woods, D. et al. (2010), Behind Human Error Behind Human Error (2 (2nd nd ed.), Ashgate, pp.38 ed.), Ashgate, pp.38- -39, 244 39, 244- -246 246
  • 28. The Passion The Passion Copyright Copyright Muschara Muschara Error Management Consulting, Error Management Consulting, LLC LLC 28