Human Performance Highly Reliable Organizations Todd Conklin PhD Human Performance Improvement/ HRO Toddconklin@gmail.com

Never take a sleeping tablet and a laxative tablet at the same time. In any order… Conklin

Accidents Time The Safety Journey So Far… Compliance Design Fatality Behaviors Policy/Rules Enforcement Accidents Design Human Factors Process Safety Standardized Systems Fatality Serious Event Not like others NO near misses Exist in success Understand work Human Performance New View Not Individual Organizational issues Identified Time Conklin

Traditional Safety Safety Differently Workers are the problem to be fixed. We fix safety by making workers better. We must tell workers what to do and, perhaps more importantly, not to do. Safety is the absence of accidents. Workers are not the problem – They are the problem solvers. We don’t tell our organizations what to do – ask them what they need. Safety is not the absence of accidents – it is the presence of capacity. Conklin

Capacity. Safety is not the absence of Accidents. Safety is the presence of Defenses. Capacity. Conklin

Mariners are as safe as they need to be, Without being too safe, in order to be productive. Conklin

Until They’re NOT..

“ To understand failure…we must first understand our reaction to failure.” — Sidney Dekker Human Performance Conklin

Sharp End Blunt End Highest Mariners/ Influence Highest Operators Over System Mariners/ Operators Highest Injury Potential Front-line Supervisors Managers Leaders Company Customers Regulators Blunt End Conklin

3 Pre-Accident Investigations, Conklin 2013 Parts of an Event Conklin

Mariner’s Don’t Cause Failures. Mariner’s Trigger Latent Conditions That Lie Dormant In Organizations Waiting for This Specific Moment In Time.

We desire seductively unambiguous information about events. Conklin

Shift your thinking from “Who Failed” to “What Failed” Conklin

Mariners Are Masters of Complex Adaptive Behavior… Conklin

We must stop seeing the Mariner as problems to be fixed. But, as the Solution to be harnessed. Conklin

Workers Discover Safety While Working… The Gray Area: Uncertain interpretation of Safe work Clearly Safe to do Work Clearly Not Safe to do Work Workers Discover Safety While Working… Conklin

After the Event, Safety is Clear… Clearly Safe to do Work Clearly Not Safe to do Work Event After the Event, Safety is Clear… Conklin

Safety Understood: Drift Start Of Job Safety Understood: Drift Conklin

Is the juice worth the squeeze? Conklin

The Power of Early Hazard ID Capacity Identified or Discovered Problem Conklin

The Power of Early Hazard ID Identified or Discovered Problem Capacity Conklin

Safety is not the absence of Accidents. Safety is the presence of Capacity. Conklin

PreAccident Investigation Podcast