Accident Incidents - The Human Part 050318 PDF

Accidents &
Incidents:
The Human Part
Presented by: Bill Rigot
May 3, 2018
Agenda
 The Newtonian View of the World

 The “New View”
 Workers as Hazards or Heroes
 Learning Teams
 The Role of Managers and Supervisors as Motivators for Safety
2
First law of safety
Never take a sleeping pill

and a laxative at the same
time
In any order …..
3
First corollary
Never remove a safety

barrier
that has a dent in It
4
Two Views of Failure
Newtonian Complex-Adaptive
5
Newton’s Laws of Motion
I. A body in motion stays in motion; a body at rest stays at

rest… unless acted upon by another force
II. F = MA
III. For every action there is an equal and opposite reaction
6
The Significance of Sir Isaac
 The 3rd Law forms the basis of our notion of a “Root Cause”
 Root Cause Analysis (RCA) is essentially a retrospective and
linear look at accidents
 We believe (erroneously) that we can back calculate an
accident or event back to its root
7
What if Newton is Wrong?
8
A New View
9
Normal
Start Work
Event
Of Context:
Job Learning
Event
Normally
Successful!
Hazard
Safety Understood:
Drift and Accumulation
Used by permission; Todd Conklin
10
The Worker as Hazard or
Hero?
 Are workers to be protected against because of all the errors

they make?
OR
• Do workers adapt constantly to get the job done safely and

without which a company cannot be successful
11
Why do we perform
investigations?
 Blame and punish
OR
 Learn and Improve
12
You can’t do both
13
14
Thought Exercise
 A bat and ball cost $1.10

 The bat costs one dollar more than the ball
 How much does the ball cost?
Daniel Kahneman, Thinking, Fast and Slow, 2011

15
Was your answer 10¢????
16
Try This:
 Y= price of the ball

 X= price of the bat
 X + Y = $1.10
 Y + $1.00 = X
 (Y + 1.00) + y = 1.10
 2Y = .10
 Y = .05
17
10¢ is the result of “fast” thinking
5¢ is the result of “slow” thinking
Learning Teams try to stay in the “slow”

thinking mode most of the time
18
Learning Team Phases*
1. Determine the need for a Learning Team

2. First session: Learning Mode only
3. Provide “soak time”
4. Second session: Start in Learning Mode
5. Define current defenses/Build new ones
6. Tracking actions and criteria for closure
7. Communicate to other applicable areas
*Todd Conklin, Pre-Accident Investigations; Better Questions

19
1. Determine the Need for a
Learning Team
 Every variance from expected results may be worth

investigating
 Some variances are more information rich than others
 Where is context important?
 Start with events that cause actual harm
 Next priority are near misses (near hits)
 You don’t have enough time or money to investigate
everything
20
2. First Session: Learning Mode
only
 Gather the team

 Explain the process
 Goal setting & expectations
 Do some instruction on New View vs. Old View thinking
 No solutions
 Ask “how” not “why”
 Describe how work gets done
 What conditions needed to exist for this event to take place
21
3. Provide Soak Time
 Ideally provide a day to let the learning from the first session
soak in
 It’s OK to gather other information
 It’s also OK to add additional members to the team
22
4. Second Session: Start in
Learning Mode
 Recap learning from previous session

 Add new thoughts gained from soak time
 Transition from learning to action
 It’s time to begin to define solutions
23
5. Define current Defenses/Build
New Ones
 What defenses were you relying on to prevent this from

happening?
 How effective were they?
 What else do you need to keep this from happening?
 Micro-experiment to see what might work
24
6. Tracking actions and criteria
for closure
 Solutions must be mutually agreed on by the team, and

managers who have the resources to dedicate to the solutions
 Right now or later?
 Why don’t workers fix problems?:
 It’s not my job to fix it
 I’ll get in trouble if I fix it
 I don’t have authority to fix it
25
7. Communicate to other
applicable areas
 Learning Teams give workers the confidence to work safely

after an upset
 Learning Teams give the company the capacity to work more
safely
 Is there other extent out there?
 Extent of condition
 Extent of cause
26
Learning Team Phases
1. Determine the need for a Learning Team

2. First session: Learning Mode only
3. Provide “soak time”
4. Second session: Start in Learning Mode
5. Define current defenses/Build new ones
6. Tracking actions and criteria for closure
7. Communicate to other applicable areas
27
Some Considerations on
Learning Teams
 Learning Teams often conflict with well established

confirmation bias
 The desire to blame and punish is often more powerful than
the desire to learn and improve
 Newton’s Third Law often gets in the way in technical
organizations
28
The Role of Managers and
Supervisors
 Sidney Dekker:
 “To understand failure…we must 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 “
29
Immediate Steps
Successful organizations seem to do four things very well:

• Constantly predicting the next failure
• Consistently reducing operational complication
• Respond with urgency to pre-cursor data
• Respond to actual events with deliberation
44
Questions?
45
For More Information
 Bill Rigot
 [email protected]
 706-627-7590
 ITI HPI Class: July 9/10 Houston

 ITI Accident Investigation Class: July 11 Houston
View the ITI Human Performance

Improvement
full course details @ iti.com/hpi
32

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Accidents &

 The Newtonian View of the World

Never take a sleeping pill

Never remove a safety

I. A body in motion stays in motion; a body at rest stays at

 Are workers to be protected against because of all the errors

• Do workers adapt constantly to get the job done safely and

 Blame and punish

 Learn and Improve

 A bat and ball cost $1.10

Daniel Kahneman, Thinking, Fast and Slow, 2011

 Y= price of the ball

Learning Teams try to stay in the “slow”

1. Determine the need for a Learning Team

*Todd Conklin, Pre-Accident Investigations; Better Questions

 Every variance from expected results may be worth

 Gather the team

 Recap learning from previous session

 What defenses were you relying on to prevent this from

 Solutions must be mutually agreed on by the team, and

 Learning Teams give workers the confidence to work safely

1. Determine the need for a Learning Team

 Learning Teams often conflict with well established

Successful organizations seem to do four things very well:

 ITI HPI Class: July 9/10 Houston

View the ITI Human Performance

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