1. Human Performance Highly Reliable Organizations
Todd Conklin PhD
Human Performance Improvement/ HRO

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

4. 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

5. 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

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

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

8. Until They’re NOT..

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

10. 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

11. 3
Pre-Accident Investigations, Conklin 2013
Parts of an Event
Conklin

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

13. We desire seductively unambiguous information about events.
Conklin

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

15. Mariners
Are Masters of
Complex Adaptive
Behavior…
Conklin

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

17. 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

18. 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

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

20. Is the juice worth the squeeze?
Conklin

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

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

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

24. PreAccident
Investigation
Podcast