The Misfortune Murphy Model

1. Will help us understand how human errors result in accidents Will assist us in understanding the root causes to an accident Will illustrate the role of Safety Management Systems (SMS) in preventing accidents Will help us understand what WE can do to help prevent future accidents The Misfortune Murphy Model

2. Latent Conditions

3. Management Decisions set up “Latent Conditions” Management Decisions

4. Latent Conditions A system condition (policy, decision or “norm”) that lays dormant until an active failure normally brings it to light They are there but often not recognized as dangerous until too late

5. Set the “scene” for the Active Failure to occur Seem like good ideas at the time May lay dormant for a long time When all the conditions are “wrong” an accident occurs if there is no Safety Net to stop it. The Safety Net may be present however it has a hole in it (not being followed) Management Decisions • Management Decisions set up “Latent Conditions”

6. Latent Conditions Latent Conditions

7. Line Management Decisions “Latent Conditions” Are decisions made based on what they think the management really wants Are there but are not recognized as potentially dangerous May also lay dormant for a long time When all the conditions are “wrong” an accident occurs if there is no Safety Net to stop it The Safety Net may be present however it has a hole in it (not being followed) Line Management Decisions

8. Latent Conditions Latent Conditions Latent Conditions

9. Preconditions - The Dirty Dozen • Set the person up to make the active error • Are often a combination of more than one of the Dirty Dozen 7. Lack of Resources 8. Pressure 9. Lack of Assertiveness 10. Stress 11. Lack of Awareness 12. Norms 1. Lack of Communication 2. Complacency 3. Lack of Knowledge 4. Distraction 5. Lack of Teamwork 6. Fatigue Preconditions To a Human Error

10. Active Failures Latent Conditions Latent Conditions Latent Conditions

11. The Active Failure • The “guilty party” who makes the mistake that results in a human error • It will be an action or lack of action that results in the error • It is the RESULTbutNOT the CAUSE

12. Active Failures Are Usually Productive Activities That Involve an Unsafe Act • Is usually very experienced • Has no intention of making the error (He knows better) • Often has no idea how he could have been so “careless” • Will often punish himself more than the system can • Is very unlikely to ever do it again The “Guilty Party” The Guilty Party

13. Active & Latent Failures Active Failures Latent Conditions Latent Conditions Latent Conditions

14. Last chance to prevent the accident from occurring If there is no Safety net in place then it is a Latent Failure The Safety Net may be present however it has a hole in it (not being followed) If the Safety net is not being used it is an Active Failure Safety Nets How many times does the chain of events get all the way to the Safety net and is stopped there?

15. Active & Latent Failures Active Failures SMS Incident Drip Tray Latent Conditions Latent Conditions Latent Conditions

16. Serves to catch the “near misses” that could have continued on to cause an accident Requires someone to “fess up” and report the “near miss” Requires a system to take and analyze (risk assess) the data in the “drip tray” The system will then use this information to “plug or reduce the size of some of the holes” that allow the chain of events to occur This results in fewer accidents We learn from an accident we didn’t have The SMS Incident Drip Tray

17. 10-20% 80-90% Active & Latent Failures Active Failures SMS Incident Drip Tray Free Lesson Tray Latent Conditions Latent Conditions Latent Conditions

18. YOU are the person who has the “near misses” YOU are the one who can put information into the “Incident Drip Tray” YOU can provide the information that will help “plug the holes” YOU can provide the “Free Lessons” that enable the organization to learn without having to have an accident SMS will require YOUR input to work YOU Are the Key to Safety

19. Any Questions?