Humans, Error, and Organizations…

1. Humans, Error, and Organizations… The Socio-Technical Relationship That Drives Our Understanding of… (and subsequent reaction to…) Organizational Failure. Todd Conklin, Ph.D. Safety Improvements Initiative Office Los Alamos National Laboratory

2. The Law of Unintended Consequences… Never take a sleeping pill and a laxative at the same time…

3. Remember… Never remove a safety barrier that has dents in it.

4. Safety Redefined… • Safety is not the absence of accidents • Safety is the presence of defenses in your processes, procedures, and methods. • In short… • What we do for a living is keep failure from being successful.

5. In my observation… People are as safe as they need to be, without being overly-safe, in order to be efficient.

6. When Good Pets Go Bad

7. Human Performance “ To understand failure…we must first 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”. — Sidney Dekker

8. Think About This • Workers don’t cause events. • Workers trigger latent conditions that exist in systems, processes, procedures, and expectations that always lie dormant on the job-site.

9. Murphy’s Law Revisited • Anything that can go wrong…. • Probably won’t.

10. Accident Defined: An Unexpected Combination of Normal Variability • We must strive to understand that accidents don’t happen because people gamble and lose. • Accidents happen because: • the person believes that what is about to happen is not possible… • or what is about to happen has no connection to what they are doing… • or, that the possibility of getting the intended outcome is well worth whatever risk there is.

11. The Individual People are fallible, and even the best make mistakes. …and your best people are out there making mistakes right now…

12. Human Errors System Induced Error Operational Upsets Slip, trip or lapse Human Error Equipment Failures Origins of Human Error

13. Exercise How many times does the uppercase or lowercase letter “F” appear in the following sentence? Finished files are the re- sult of years of scientific study combined with the experience of many years. Finished files are the re- sult of years of scientific study combined with the experience of many years.

14. Limitations of Human Nature Errors arise directly from the way the mind handles information, not through stupidity or carelessness. — Dr. Edward de Bono

15. 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 vs. New View of Human Error

16. On Error Identified error without consequence is a good thing. Error occurs often enough to expose weaknesses in defenses, organizational processes, procedures, and the culture.

17. Consequence Creates Error The Central Dilemma is.. • The organization wants to know everything that goes on…but… • The organization cannot accept everything that goes on. The thought that events can “just happen” is unacceptable to the organization’s understanding of itself.

18. Error is Often Attributed • Errors exist independently of our looking for errors • Your perspective, by definition, does not allow you to see the worker’s perspective. • The determination that a worker made an error is a judgment that is passed organizationally from you to the worker’s decisions.

19. To err is human … To deviate is also human … People are outcome-based and value immediate and certain results They make decisions to achieve the desired results As they try to do more with less, they drift away from expected behaviors

20. Traditional View of Error and Violation Deviation from Expected Behavior Error The Grey Area “Intentional Variation” Violation

21. Work as Imagined Vs. Work in Practice Normally Successful!

22. The Key Event Prevention Happens Through Learning

23. The Organization Individual behavior is influenced by organizational processes and values. Systems Drive Behavior.

24. Organizational Processes Workplaces and organizations are easier to manage than the minds of individual workers. You cannot change the human condition, but you can change the conditions under which people work. — Dr. James Reason

25. Organizational Values Operational upsets can be avoided by understanding the reasons mistakes occur and applying the lessons learned from past events.

26. Barriers to a Learning Organization • 20 years of experience = 1 year of experience repeated 19 times • Looking outside the organization is easier then asking the difficult internal questions • We confuse our scientific quest for cause with our emotional need for an explanation

27. Human to Systems Interface • People will never perform better than what the organization will allow • If a system relies on people doing the right thing every time, it will fail • No working system remains in stasis

28. Safety Redefined… • Safety is not the absence of accidents • Safety is the presence of defenses in your processes, procedures, and methods.

29. Immediate Steps Successful organizations seem to do four things very well: • Constantly predicting the next failure • Consistently reducing operational complexity • Responding with urgency to pre-cursor data • Respond to actual events with deliberation

30. Conference Homework • Be more - Be just a bit smarter, nicer, more involved, happier, and a better co-worker. • Be the person who makes people feel good about who they are…no matter who they are or what they do. • Perceive More about the world around you…and by doing that you will make the world a much better place in which we work. • Build “Communities of Thought.” • Fake It Until You Make It. • Start Right Now.

31. Questions? Bigtodd@lanl.gov