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© Baines Simmons Limited 2004 One small step for management One small step for management one giant leap for error management one giant leap for error management Keven Baines Keven Baines Director of Baines Simmons Limited Director of Baines Simmons Limited
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Page 1: © Baines Simmons Limited 2004 One small step for management one giant leap for error management Keven Baines Director of Baines Simmons Limited.

© Baines Simmons Limited 2004

One small step for management One small step for management one giant leap for error managementone giant leap for error management

Keven Baines Keven Baines

Director of Baines Simmons LimitedDirector of Baines Simmons Limited

Page 2: © Baines Simmons Limited 2004 One small step for management one giant leap for error management Keven Baines Director of Baines Simmons Limited.

© Baines Simmons Limited 2004

The conference objectiveThe conference objective

• To provide information and ideas on "best practice" with respect to training approaches, methods, techniques, tools and subject matter.

My presentation objectivesMy presentation objectives

How you really make it workHow you really make it work

By reviewing our experience of the last two yearsBy reviewing our experience of the last two years

Page 3: © Baines Simmons Limited 2004 One small step for management one giant leap for error management Keven Baines Director of Baines Simmons Limited.

© Baines Simmons Limited 2004

What we know…What we know…

The spread of contributing factors is not concentrated at the The spread of contributing factors is not concentrated at the active failure end or the man with the spanneractive failure end or the man with the spanner

Accident causation is not simply restricted to active human Accident causation is not simply restricted to active human failure:failure:

1.1. Organisational processesOrganisational processes -- 27.8%27.8%

2.2. Local working conditionsLocal working conditions -- 20.9%20.9%

3.3. Latent FailuresLatent Failures -- 19.6%19.6%

4.4. DefencesDefences -- 19.6%19.6%

5.5. Active failuresActive failures -- 12.2%12.2%

David G.P. Stephens 1996

Page 4: © Baines Simmons Limited 2004 One small step for management one giant leap for error management Keven Baines Director of Baines Simmons Limited.

© Baines Simmons Limited 2004

““Just give the HF training to my spanner turners’ and Just give the HF training to my spanner turners’ and the problem will go away at minimal cost to the the problem will go away at minimal cost to the business...” business...”

But we routinely hear…But we routinely hear…

Page 5: © Baines Simmons Limited 2004 One small step for management one giant leap for error management Keven Baines Director of Baines Simmons Limited.

© Baines Simmons Limited 2004

What we (almost) never hear isWhat we (almost) never hear is

““Our senior management team to really need Our senior management team to really need to understand what this (required) programme to understand what this (required) programme could do for us could do for us beforebefore we do we do anyany staff training” staff training”

Page 6: © Baines Simmons Limited 2004 One small step for management one giant leap for error management Keven Baines Director of Baines Simmons Limited.

© Baines Simmons Limited 2004

Hands-on staff perceptionsHands-on staff perceptions• The most commonly voiced concern we hear from production, The most commonly voiced concern we hear from production,

supervisory and support staff (during their HF/EMS training course) supervisory and support staff (during their HF/EMS training course) is…is…

• ““this is all very interesting, and yes at last we are discussing what its this is all very interesting, and yes at last we are discussing what its really like out their in the workshop, hangar or line…but how much really like out their in the workshop, hangar or line…but how much training has our management team had on this”?training has our management team had on this”?

• Our answer is…Our answer is…

• If we have the order right a senior manager already opened the If we have the order right a senior manager already opened the course and said this himselfcourse and said this himself

• Staff should be shown how they can effect change in the systemStaff should be shown how they can effect change in the system

• They should be shown how the error management system works They should be shown how the error management system works and the part they are expected to playand the part they are expected to play

Page 7: © Baines Simmons Limited 2004 One small step for management one giant leap for error management Keven Baines Director of Baines Simmons Limited.

© Baines Simmons Limited 2004

We all know that there is an ideal order of We all know that there is an ideal order of roll-out roll-out

• We visit many organisations who are putting all their We visit many organisations who are putting all their immediate efforts in the wrong place immediate efforts in the wrong place

• Staff training is the largest cost of compliance so the amount Staff training is the largest cost of compliance so the amount of effort expended is biggestof effort expended is biggest

• We have seen that to be successful:We have seen that to be successful:

1.1. You must first be management team focussedYou must first be management team focussed

2.2. The training cannot exist outside an error management The training cannot exist outside an error management systemsystem

Page 8: © Baines Simmons Limited 2004 One small step for management one giant leap for error management Keven Baines Director of Baines Simmons Limited.

© Baines Simmons Limited 2004

Human Factors training can Human Factors training can only be successful within an only be successful within an error management systemerror management system

Staff HF/EMInitial Training

Just culture / disciplinary policy & safety culture

Error/Contributing Factor

Data analysis

Your existingQA system/Continuous

Improvement process

Maintenance Error/Hazard

Reporting system

Maintenance Error investigation

using trained investigators

Notification of bad data

to the author

Management training

• TNA + cultural assessment• Fatigue management • Incomplete task/shift handover• Drafting good procedures• Planning wrt HF…etc.

Recurrent HF/EM training & continuous feedback to staff

Pictures with permission of Baines Simmons Limited © 2004

Page 9: © Baines Simmons Limited 2004 One small step for management one giant leap for error management Keven Baines Director of Baines Simmons Limited.

© Baines Simmons Limited 2004

Changing perceptionsChanging perceptions

• Again a common problemAgain a common problem

• Sometimes due to the fact that this HF thing has been around Sometimes due to the fact that this HF thing has been around since the early ninetiessince the early nineties

• The management team will undoubtedly have formed a mental The management team will undoubtedly have formed a mental model of what this Human Factors thing is all about. model of what this Human Factors thing is all about.

• It is one of the most difficult things that we have to overcome, It is one of the most difficult things that we have to overcome, before we can move forwards.before we can move forwards.

• But we have a solution…and its from the regulator But we have a solution…and its from the regulator

Page 10: © Baines Simmons Limited 2004 One small step for management one giant leap for error management Keven Baines Director of Baines Simmons Limited.

© Baines Simmons Limited 2004

The Golden opportunityThe Golden opportunity

• What should this vital manager’s session cover? What should this vital manager’s session cover?

• Break their misconceptions - communicate what Break their misconceptions - communicate what thisthis programme is programme is reallyreally all about all about

• An especially difficult task if the company has past An especially difficult task if the company has past (incomplete) experience of partial HF programme (incomplete) experience of partial HF programme

• Start small and build on it…wet their appetites…leave Start small and build on it…wet their appetites…leave them wanting morethem wanting more

Page 11: © Baines Simmons Limited 2004 One small step for management one giant leap for error management Keven Baines Director of Baines Simmons Limited.

© Baines Simmons Limited 2004

Who should attended?Who should attended?

• Who are your key managers? Not always status, possibly Who are your key managers? Not always status, possibly influence…influence…

• How vital do you consider his/her attendance? How vital do you consider his/her attendance?

• Training session only goes ahead if these key people are in Training session only goes ahead if these key people are in attendance attendance

• What managers?What managers?

Page 12: © Baines Simmons Limited 2004 One small step for management one giant leap for error management Keven Baines Director of Baines Simmons Limited.

© Baines Simmons Limited 2004

How do you affect managers attitudes?How do you affect managers attitudes?

1.1. Managers TNA, one objective: Getting buy-in Managers TNA, one objective: Getting buy-in

2.2. Light on Human Factors – heavy on organisational cultureLight on Human Factors – heavy on organisational culture

3.3. Get them to list risks to the business in their groups – let Get them to list risks to the business in their groups – let them talkthem talk

4.4. DemonstrateDemonstrate how the error management system (which how the error management system (which includes HF training) will help mitigate those risks includes HF training) will help mitigate those risks

5.5. Ensure that they leave with a clear understanding that Ensure that they leave with a clear understanding that error lives in us all, not just a few isolated poor error lives in us all, not just a few isolated poor performers…performers…

6.6. Ensure its about their company… Ensure its about their company…

Page 13: © Baines Simmons Limited 2004 One small step for management one giant leap for error management Keven Baines Director of Baines Simmons Limited.

© Baines Simmons Limited 2004

““But we don’t have a problem But we don’t have a problem example here”…example here”…

Page 14: © Baines Simmons Limited 2004 One small step for management one giant leap for error management Keven Baines Director of Baines Simmons Limited.

© Baines Simmons Limited 2004

““We don’t think we have procedure We don’t think we have procedure compliance problems”compliance problems”

Page 15: © Baines Simmons Limited 2004 One small step for management one giant leap for error management Keven Baines Director of Baines Simmons Limited.

© Baines Simmons Limited 2004

How do you affect managers attitudes?How do you affect managers attitudes?

8.8. They should leave wanting an error management system, They should leave wanting an error management system, because its good for business.because its good for business.

9.9. Create a common language regarding Create a common language regarding error/violation/system induced etc… error/violation/system induced etc…

10.10. Ensure that they go away hungry to see the error budget Ensure that they go away hungry to see the error budget

11.11. Get the whole top team together - away from the facility Get the whole top team together - away from the facility (this is never going to happen, but aiming high means (this is never going to happen, but aiming high means settling somewhere in the middle)settling somewhere in the middle)

12.12. Real success examplesReal success examples

Page 16: © Baines Simmons Limited 2004 One small step for management one giant leap for error management Keven Baines Director of Baines Simmons Limited.

© Baines Simmons Limited 2004

What is the ultimate prize?What is the ultimate prize?

• If you achieve these 12 training objectives during the senior team If you achieve these 12 training objectives during the senior team session you might just result in a session you might just result in a pullpull approach to your error approach to your error management problem management problem

• management team will fully understand what they have really management team will fully understand what they have really committed to in the safety and quality policy…committed to in the safety and quality policy…

• They won’t want to tick the box…one size fits all approach to the They won’t want to tick the box…one size fits all approach to the human factors and error management training human factors and error management training

Page 17: © Baines Simmons Limited 2004 One small step for management one giant leap for error management Keven Baines Director of Baines Simmons Limited.

© Baines Simmons Limited 2004

we always cover:we always cover:

• Business risks – Business risks – they know what they are, just ask themthey know what they are, just ask them

• How big is your companies Error Iceberg – How big is your companies Error Iceberg – they don’t know this, but they don’t know this, but they will have a good guessthey will have a good guess

• Who owns your error budget – Who owns your error budget – nobody does, so make them squirmnobody does, so make them squirm

• Return on Investment – Return on Investment – they will ‘get’ this without too much help they will ‘get’ this without too much help from youfrom you

• Organisational culture – Organisational culture – SHoMe or similar, make them see the truth SHoMe or similar, make them see the truth from the iceberg of ingorancefrom the iceberg of ingorance

• How your EM programme will reduce your business risks – How your EM programme will reduce your business risks – by now by now they are putty in your handsthey are putty in your hands

• Success stories – ask…go and see…and recount – Success stories – ask…go and see…and recount – now they are now they are running out the door hunting for error!running out the door hunting for error!

Page 18: © Baines Simmons Limited 2004 One small step for management one giant leap for error management Keven Baines Director of Baines Simmons Limited.

© Baines Simmons Limited 2004

Summary - how to ensure your HF training Summary - how to ensure your HF training deliversdelivers

1.1. Start with management team training Start with management team training – golden – golden opportunityopportunity

2.2. Your HF training must exist within an error management Your HF training must exist within an error management programme programme -- alone it will cost the same and fail to return alone it will cost the same and fail to return on your investmenton your investment


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