Human Performance Todd Conklin PhD Royce Railey Sr. Safety Advisor Los Alamos National Labs toddconklin@gmail.com Royce Railey Regional S&H Manager Cintas Corporation The Curious Organization

Never take a sleeping pill And a laxative At the same time… …In any order The Curious Organization Conklin/Railey

Safety is not the absence of Accidents. Safety is the presence of defenses. The Curious Organization Conklin/Railey

People Are As Safe As They Need To Be, Without Being Overly Safe… In Order To Get Their Job Done. The Curious Organization Conklin/Railey

“ To understand failure…we must first understand our reaction to failure.” — Sidney Dekker Human Performance The Curious Organization Conklin/Railey

Workers Don’t Cause Failures. Worker’s Trigger Latent Conditions That Lie Dormant In Organizations Waiting for This Specific Moment In Time. Conklin/Railey

Ask How Not Why! The Curious Organization Conklin/Railey

Worker Behavior and Work Processes In Parallel… We Must Manage Worker Behavior and Work Processes In Parallel… Human Performance The Curious Organization Conklin/Railey

Principles of Human Performance People are fallible Error-likely situations are predictable Individual behaviors are influenced Operational upsets can be avoided Management’s response to failure matters Principles of Human Performance The Curious Organization Conklin/Railey

People are fallible, and even the best make mistakes. Human Performance Principle 1: People are fallible, and even the best make mistakes. Conklin/Railey

Human Error Expertise Identification Exercise Conklin/Railey The Curious Organization Conklin/Railey

Finished files are the re- sult of years of scientific 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. The Curious Organization Conklin/Railey

Limitations of Human Nature “Mistakes arise directly from the way the mind handles information, not through stupidity or carelessness.” -Edward de Bono PhD Limitations of Human Nature The Curious Organization Conklin/Railey

= Error is not a choice. Mistakes Violations Conklin/Railey The Curious Organization Conklin/Railey

Workers Are Masters of Complex Adaptive Behavior… Conklin/Railey The Curious Organization Conklin/Railey

Workers FIND Safety at Work… Clearly Safe to do Work Clearly Not Safe to do Work The Gray Area: Uncertain interpretation of Safe work Unclassified Workers FIND Safety at Work… The Curious Organization Conklin/Railey

After the Event, Safety is Clear… Clearly Safe to do Work Clearly Not Safe to do Work Event Unclassified After the Event, Safety is Clear… The Curious Organization Conklin/Railey

Accidents happen when workers find themselves in situations where it is easy to get hurt and hard to be safe. The Curious Organization Conklin/Railey

Error-likely situations are predictable, manageable, and preventable. Human Performance Principle 2: Error-likely situations are predictable, manageable, and preventable. The Curious Organization Conklin/Railey

Events aren’t predictable, But the environment in which Events may happen is… The Curious Organization Conklin/Railey

Where will the next safety event happen at your site? Predictability Conklin/Railey

Collectively tell the STORY of where the next event may happen. The story of all the little events…. Conklin Conklin/Railey

Management’s response to failure matters. Human Performance Principle 5: Management’s response to failure matters. The Curious Organization Conklin/Railey

Work as Imagined Vs. Work in Practice Drift and Accumulation Normally Successful! Work as Imagined Vs. Work in Practice The Curious Organization Conklin/Railey

The Power of Early Hazard ID Solution Space Identified or Discovered Problem The Curious Organization Conklin/Railey

The Power of Early Hazard ID Identified or Discovered Problem Solution Space Identified or Discovered Problem The Curious Organization Conklin/Railey

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

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. The Curious Organization Conklin/Railey

The Challenge… Swarm and Fix problems. Spread new knowledge. 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 Curious Organization Conklin/Railey

Safety is not the absence of Accidents. Safety is the presence of defenses. The Curious Organization Conklin/Railey