Behavior+Depends+on+Risk

8/22/2019 Behavior+Depends+on+Risk

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Session: Wednesday 7 October 2:40 pm TapRooT Summit Nashville 2009

ByJim Whiting

[email protected]

Behavior depends on Risk Perception


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Human GOOFUps are always [ 100% not 90% or 95 % ]

part of causation of real incidents

and always part of causes of risks of whatif incidents.

GOOFUps occur when we dont do what we are :

! Supposed to do

! Should have done

! Could have done!Wanted to do

! Tried to do

!Needed to do

! Told to do

! Expected to do

!Obliged to do

!Trained to do copyright 2009 risk@workplaces pty ltd QRA.27


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Less error prone design ?

Now design is ergonomic


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Age 20 Age 60 Age 75

Vision Decrement with AGE


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Risk Perception Avoid OverConfidence

Remember EVERYTHING ispossiblebut some things are moreprobable than others

Beware the black swan

Avoid Absolute words like :

eliminate, stop, prevent, zero

We reduce the risk of recurrence of incidents

We dontpreventthem

copyright 2009 risk@workplaces pty ltd


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Avoid OverConfidence

1907

"When anyone asks me how I

can best describe my experience

in nearly forty years at sea,

I merely say, uneventful.

Of course there have been winter gales, and storms and fog and the like. But in all

my experience,

I have never been in any accident ... of any sort worth speaking about.

I have seen but one vessel in distress in all my years at sea. I never saw a wreckand never have been wrecked nor was I ever in any predicament that threatened

to end in disaster of any sort.

5 Years later, 1912 Captain Smith was Master of the Titanic on its only voyage.



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RM can never

even considercopout concepts

such as bad luck



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Black Swan PrinciplesWhen it comes to generalizations like all swans are white, it is

enough for one black swan to existfor this conclusion to be false.

BEFORE you find the black swan,no amount of information about white swans

whether you observed 1, 100, or 1,000,000 of them

could help you to determine whether or not the generalization

all swans are whiteis true or not.


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Black Swan Principles

! Beyond any past personal experiences ?

! Believed to be impossible ? Improbable ?

! Low [ or Zero ? ] Likelihood ?

! Risks that are low Likelihood but high Consequence


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! Sweden driving on the right

! Electrical linesmen working after/during a

night storm

! Street lights out an intersection

! US submarine captains early in WW2

! Is there an economic equivalent of wartime

risk taking in stressed companies ?

Examples of Behaviour

depending on Risk Perception


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Human GOOFUps are always [ 100% not 90% or 95 % ]

part of causation ofreal incidents

and always part of causes ofrisks of whatif incidents.


! Supposed to do

! Should have done


! Tried to do

!Needed to do

! Told to do

! Expected to do

!Obliged to do



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Human Errors often defined as the goof-ups

where there was no choice or intent

GOOFUps can be either :

! intentional(substandard practices, unsafe acts , at risk

behaviours , violations / breaches of rules OR

! unintentional

(errors, mistakes, no choice or intent andsometimes not event aware of the correct

behaviour).

copyright 2009 risk@workplaces pty ltd QRA.27


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Human Errors

Human Reliability Analysis identifies various types of human

errors:-! error of omission not carrying out the required action; and! error of commission! difficulties in carrying out a required action adequately;

! too much or too little force! without the required accuracy

! carried out at the wrong time! carried out in the wrong sequence

!perform other extraneous actions;! un-required actions carried out instead of or in addition to,

the required action.

!HRA identifies error-tolerant and error-recovery actions andparts of systems or procedures where there are opportunitiesfor human or mechanical actions to recover from previouserrors.

!HRA depends strongly on behavioural sciences, ergonomics,human factors engineering and reliability engineering.



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Human Reliability Analysis (HRA)

Human reliability analysis (HRA) considers howhumans interact with their tasks, equipment, tools, workmethods and work environment. The human elementand its effects on other parts of any system are the mostunpredictable; hence most unreliablepart of anysystem. This makes the estimation of probabilities ofhuman error notoriously difficult.

Human interactionprovides both positive risk

treatments and the errors which influence systemperformance, safety and productivity. Human action isoften the only defence in preventing an incidentscenario progressing fully to its unwanted outcomes.



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" Situational Awareness & associated Risk of Errorsare important aspects in risk perception/identification

" Risk of an individual making an error:

! is often related to the persons blindness to the situation

" Situational awareness:

! a persons perception of what risk factors are present or about

to arise in the work environment at any moment in time

! the persons understanding of their potential effects both in the

immediate present and future

Human Reliability Analysis (HRA)


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The ultimate Activator A of behaviour is the persons perception

of the level of risk of negative and positive consequences

associated with the situation and the use of certain types ofbehaviour

Perception of risk is a function of:

how much the person believes he/she is personally

exposed and susceptible to harm (It wont happen to me)

personal experience with the situation or task and

observation of others in the same situation

how much the person believes the outcome is serious how much the person believes that control actions

would be effective and worth it.

Behaviour depends on Risk Perception

copyright 2009 risk@workplaces pty ltd E.18


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To be confident that employees at all levels

understand and

may possibly want to or need to change

their risk taking behaviors at work,

we need to be confident that they can

understand & evaluate the risks adequately,

AND perceive the risks adequatelyAND assess the risks adequately

AND calculate the risks adequately.

Behaviour and Risk Perception

copyright 2009 risk@workplaces pty ltd AAA.9


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An individuals or workgroups

tolerability of risk

depends on personal evaluation of costs /benefits based on values & perceptions

at all levels :-

personal,

family

group, corporate

social copyright 2009 risk@workplaces pty ltd E.19


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! associated with dread words! assoc with benign words

! targets children! targets adults

! Info from a non-trusted source! Info from a trusted source! catastrophic consequences! minor consequences

! inequitable, unfair distribution! equitable, fair distribution

! unusual, exotic! familiar characteristics

! negative effects immediate! negative effects delayed

! effects statistically uncertain! effects appear stat. certain

! synthetic / artificial! natural components

! little or no obvious benefit!benefit to exposed person

! controlled by others! under own personal control

! externally imposed! voluntary / internal / choice

Perceived as less tolerablePerceived as more tolerable


Perception Factors for Risk Tolerability


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Possible Risk Tolerability versus Level of Perceived Risk

Level of Perceived Risk HighLow

HighlyTolerable

Highly

INtolerable

Neutral

"risk avoiders" ( avoid activities due to the risks involved),

"risk reducers" ( participate in high risk activities in spite of the risks involved),

"risk optimisers" ( participate in high risk activities partly because of the risks involved).

Risk

Reducer

Risk

Optimiser

RiskAvoider

personality traits ?? attitudes are predicted to be reasonably stable over time


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" On a day-to-day basis,

the risk takers and the risk makers arethe appropriate risk managers.

" However , this assumes that :-

the risk takers and the risk makers fully knowand fully appreciate all the

positive and negative

dimensions of the risk.



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ALL safety discussions

" safety meetings of any kind

" postincident decisionmaking" employee counselling

" observationbased interactions

" work method discussions

should involve risk assessments to achieve

! aligned risk perceptions! employeeowned procedures


F B h i l C t P f Diffi lti


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Four Behavioural Concepts or Performance Difficultiesafter Marx : Patient Safety and the Just Culture: A Primer For Health Care Executives

Medical Event Reporting System Transfusion Medicine (MERSTM) 4/17/01

1. Human ErrorHuman Error is a social label. Human error is a term that we use to describe our everyday

behavior missing a turnoff on the freeway, picking up strawberry ice cream instead of chocolate

The threshold for labeling behaviour human error is very low

we make errors every day with generally minimal consequences.

2. Negligent ConductNegligence, at least in our social dialogue, is conduct subjectively more culpable than error.

Negligence, as a legal term, arises from both the civil (tort) and criminal liability systems.3. Reckless ConductReckless conduct, alternatively referred to as gross negligence, Also a legal term

involves a higher degree of culpability than negligence.

Reckless conduct in both the civil liability and criminal systems

involves conscious disregard of risk. Reckless conduct differs from negligent conduct in intent;

negligence is thefailure to recognize a risk that should have been recognized, while recklessness

is a conscious disregardof a visible, significant risk. Consider the term reckless driving.

4. Intentional Rule Violations ( always for good reasons )Most rules, procedures, and duties will require or prohibit a specific behaviour.

The intentional rule violation occurs when an individual chooses to knowingly violate a rule

while he is performing a task. This concept is not necessarily related to risk taking,but merely shows that an individual knew of or intended to violate a rule, procedure, or duty


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More

Conscious

More

AutomaticSkill- based behaviour

Rule based behaviour

Knowledge- based Behaviour

S

K

RFollowing rules or procedures as packets

of behaviour prompted by a sequence of

instructions eg cooking to a recipe

No routines or rules available.Situation only handled by conscious

reasoning based on knowledgeable

processing of factual inputs.

eg driving through a strange city with the

aid of a map and road signs

Automated Routines with little conscious

decision making or attention ,

eg riding a bike



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risk @ workplaces pty ltd

ACN 082 987 675

Copyright

ABC Model of Understanding Behaviour

ActivatorsActivators or MotivatorsWhat precedes or stimulates or prompts.. or cues

BehaviourBehaviour or ActionsWhat we do. What we observe.

ConsequencesConsequences or Outcomes Whatfollows or results fromor is produced by


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Activators


ACN 082 987 675

Copyright

Activators or motivators

Whatprecedes or stimulates orprompts or cues

!attitudes, beliefs, skills, knowledge (or ignorance), information

processing,

!goals, intentions, needs, expectations,

!prior experiences(consequences),

!risk perception ! how much the person believes in being personally susceptible to a given outcome (ie. injury or ?);

!how much the person believes the consequences or outcomes are serious;

! how much the person believes that preventative action is reasonable, practical, effective.

!temporary mental/physical/emotional states,

!environmental factors (Bradley, 1989):

* thephysical environment

(ie. geography, architecture, aesthetics ,climate, technology, tools, equipment, plant, etc.)

* the task environment

(ie. activities performed, variety, meaningfulness)

* the organisational environment(ie. systems or rules and regulations, policies and procedures, norms and roles);

* the psychosocial environment(ie. the behaviour, attitudes, moods of other people present in the immediate situation).

A very strong psychosocial influence on behaviour is that of group norms. (

peer pressure, social pressure )


Behaviour

Consequences

ABC Model of Understanding Beha io r


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Activators


ACN 082 987 675

Copyright




processing,




!

how much the person believes the consequences or outcomes are serious;! how much the person believes that preventative action is reasonable, practical, effective.












Behaviour

Consequences

risk perception how much the person believes!in being personally susceptible to a given outcome (ie. injury or ?);

! that the consequences or outcomes are serious;! that preventative action is reasonable, practical, effective.



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Activators


ACN 082 987 675

Copyright




processing,




!

how much the person believes the consequences or outcomes are serious;! how much the person believes that preventative action is reasonable, practical, effective.












Behaviour

Consequences

!prior experiences(consequences)



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Activators


ACN 082 987 675

Copyright

Consequences or Outcomes

What follows or results fromor is produced by

Consequences can include :! real or perceived changes, increases or decreases in

comfort / discomfort, ease / effort, simplicity / complexity praise / criticism / apathy, peer group approval / acceptance / rejection risks of injury / illness , risks of asset / property damage productivity, efficiency

monetary / inkind incentives, piece rates satisfaction / dissatisfaction for doing job well / badly discipline / punishment quality and quantity of information feedback

Consequences can originate from

internal sources (eg. self assessment, selffulfilment , selfappraisal)or, more commonly,external sources ( from other people and the physical environment)

The Reinforcement influence of any consequence depends on threefactors :

Value, Immediacy and Frequency of the Consequences

Value + OR eg praise, comfort, ease, approval, efficiency, moneyImmediacy sooner OR later eg immediate or delayedFrequency often / frequent / certain / consistent

OR infrequent / uncertain / inconsistent


Behaviour

Consequences

ABC Model of Understanding Beha io r E ercise


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Typical Incident Investigation Findings

* Time is saved / Job done faster

* More comfortable without equipment

* No one is injured* Team Leader ignored what he saw

* No reprimand

* Other team members liked speed

* Risk of Death much higher

* Realises he needs skill / knowledge

* Caught / trapped for 10 minutes

* Toxic gas detected after entry

* He has never been injured before

* Others in the Team dont use CSP

* General macho risktaking culture

* CSP Equipment not available

* Dont know how /no skill to do CSP

Activators

Consequences

Previous Consequence?

Yes / No ?

Yes / No ?

Yes / No ?

Yes / No ?

Yes / No ?

BehaviourSSP = Operator NOT using the

CONFINED SPACE PROCEDURE

ABC Model of Understanding Behaviour Exercise

A Confined Space Procedure

Value +/ Immediacy Frequency

risk @ workplaces ptyltdCopyright

GOOF U l


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GOOFUps are always

part of causation of real incidents

and part of risks of probable whatif incidents.


! Supposed to do

! Should have done


! Tried to do

!Needed to do

! Told to do

! Expected to do

!Obliged to do



32/33

Human Errors often defined as the goof-ups

where there was no choice or intent

GOOFUps can be either :

! intentional(substandard practices, unsafe acts , at risk

behaviours , violations / breaches of rules OR

! unintentional

(errors, mistakes, no choice or intent andsometimes not event aware of the correctbehaviour).



33/33

ALL safety discussions

" safety meetings of any kind

" postincident decisionmaking" employee counselling

" observationbased interactions

" work method discussions

should involve risk assessments to achieve

! aligned risk perceptions! employeeowned procedures


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