Todd Conklin PhD
Sr. Safety Advisor
Los Alamos National Labs
Human Performance
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Royce Railey
Regional S&H Manager
Cintas Corporation
Never take a sleeping pillAnd a laxativeAt the same time…
…In any order
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Safety is not the absence of Accidents.
Safety is the presence of
defenses.TheCuriousOrganization Conklin/Railey
People Are As Safe As They Need To Be,
Without Being Overly Safe…
In Order To Get Their
Job Done.
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*Human Performance
“ To understand failure…we must first understand our reaction to failure.”
— Sidney Dekker
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Workers Don’t Cause Failures.
Worker’s Trigger Latent Conditions That Lie Dormant In OrganizationsWaiting for This Specific Moment In Time.
Conklin/Railey
*Human Performance
We Must ManageWorker Behavior and Work ProcessesIn Parallel…
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*Principles ofHuman Performance
1.People are fallible
2.Error-likely situations are predictable
3.Individual behaviors are influenced
4.Operational upsets can be avoided
5.Management’s response to failure matters
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*People are fallible, and even
the best make mistakes.
Human Performance Principle 1:
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How many times does the uppercase or lowercase
letter“F”appear in the following sentence?
Finished files are the re-sult of years of scientificstudy combined with the experience of many years.
Finished files are the re-sult of years of scientificstudy combined with the experience of many years.
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*Limitations of Human Nature
“Mistakes arise directly from the way the mind handles information, not through stupidity or carelessness.”
-Edward de Bono PhD
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Unclassified16
*Workers FIND Safety at Work…
Clearly Safeto do Work
Clearly Not Safeto do Work
The Gray Area:Uncertain
interpretationof Safe work
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Unclassified17
* After the Event, Safety is Clear…
Clearly Safeto do Work
Clearly Not Safeto do WorkEvent
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Accidents happen when workers find themselves in situations where it is easy to get hurt and
hard to be safe.
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*Error-likely situations are
predictable, manageable, and
preventable.
Human Performance Principle 2:
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Events aren’t predictable,But the environment in whichEvents may happen is…
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The story of all the little events….
Collectively tell the STORY of where the next event may happen.
ConklinConklin/Railey
*Management’s response to failure matters.
Human Performance Principle 5:
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*Work as Imagined Vs. Work in Practice
NormallySuccessful!
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Drift and Accumulation
Solution Space
The Power of EarlyHazardID
Identifiedor Discovered
Problem
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Solution Space
Identifiedor Discovered
Problem
The Power of EarlyHazardID
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*Origins of Human Error
10%
90%30%
70%
Human Error
Slip, trip or lapse
Equipment Failures
Human Errors
Operational Upsets
System Induced Error
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*Old vs. New View of Human Error
*Human error is a cause of accidents…
*To explain failure, investigations must seek failure
*They must find people’s inaccurate assessments, wrong decisions and bad judgments
*Human error is a symptom of trouble deeper inside a system…
*To explain failure, do not try to find where people went wrong.
*Instead, find how people’s assessments and actions made sense at the time, given the circumstances that surrounded them.
OLD
NEW
Make it easy to See problems
Swarm and Fix problems.
Spread new knowledge.
Lead by developing this capacity.
*Stephen Spear, The High Velocity Edge
The Challenge…
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