1. Error Management Error management has two components: –Error reduction and –Error containment Safety is a dynamic non-event

2. Error Management Error management includes measures to –minimize error liability of individuals or teams –reduce vulnerability of particular tasks –discover, assess, eliminate error/violation producing factors in the workplace –enhance error detection –increase error tolerance of the workplace –make latent conditions more visible –improve the organization’s intrinsic resistance to human fallibility

3. Error Management Problems with existing Error Management (EM) schemes include: –fire fighting last error instead of anticipating and preventing the next –focus on active failures rather than latent conditions –focus on personal vice situational contributions –rely heavily on exhortations and disciplinary actions –employ blame-laden, meaningless terms such as “carelessness, bad attitude, irresponsibility, inattention to detail” –do not distinguish between random and systematic error-causing factors –generally do not make use of human factors knowledge regarding error and accident causation

4. Engineering a Safety Culture A safety culture can be socially engineered by identifying and creating its essential components and then assembling them into a working whole. Components of a safety culture –A reporting culture in which people are prepared to report their errors and near-misses –A just culture in which an atmosphere of trust encourages people to provide essential safety-related information and makes the boundary clear between acceptable and unacceptable behavior. –A flexible culture that is able to reconfigure itself in the face of high- tempo operations or certain kinds of danger (hierarchical mode to flatter, professional structure). Requires a major investment in training. –A learning culture that allows personnel to draw the right conclusions from the safety information system and has the will to implement major reforms when indicated

5. Engineering a Safety Culture Engineering a Reporting Culture –Five factors are important for determining both the quality and quantity of incident reports Immunity from disciplinary action (as far as practical) Confidentiality Separation of those collecting the data from those with the authority to discipline Rapid, accessible, useful, intelligible feedback to the reporting community Ease of making the report

6. Engineering a Safety Culture Engineering a Just Culture –Agreed set of principles for drawing the line between acceptable and unacceptable actions –The substitution test When faced with an accident or serious incident in which the unsafe acts of a particular person were implicated, perform the following mental test: –Substitute the individual involved with someone coming from the same domain of activity, possessing comparable qualifications and experience. –In light of how events unfolded and were perceived by those involved at the time, is it likely that the new individual would have behaved any differently? –A useful addition to the substitution test is to ask of the individual ‘s peers: “Given the circumstances that prevailed at that time, could you be sure you would not have committed the same or similar type of unsafe act?” –If the answers are “No,” then blame is probably inappropriate.

7. Engineering a Safety Culture Engineering a Flexible Culture –Culture capable of adapting effectively to changing demands –Must operate to a failure-free standard To manage complex, demanding technologies, making sure to avoid major failures that could cripple the organization To maintain the capacity for meeting periods of very high peak demand and production when they occur –Decision-making patterns that emerge from High Reliability Organizations include: Reporting errors without encouraging a lax attitude toward error commission Initiative to identify errors in procedures and nominate and validate changes Error avoidance without stifling initiative or creating excessive operator rigidity Mutual monitoring without loss of trust, confidence, or autonomy

8. Engineering a Safety Culture Engineering a Flexible Culture –HRO in high op-tempo switch fm bureaucratic, centralized modes of authority to more decentralized, professional modes: Formal rank and status decline Hierarchical rank defers to technical expertise Functional discipline, professional of work teams Feedback and (sometimes conflicting) negotiations increase in importance Feedback about “how goes it” is sought and valued –All hazardous technologies face problem of requisite variety – variety in system exceeds variety of those who must control it Stories and story telling potentially more reliable A culture that favors face-to-face communication. Work groups made up of divergent people.

9. Engineering a Safety Culture Engineering a Learning Culture –Easiest to engineer, most difficult to make work –Constituent elements (see also Senge) Observing -> noticing, attending, heading, tracking Reflecting -> analyzing, interpreting, diagnosing (also hard) Creating -> imagining, designing, planning Acting -> implementing, doing, testing –This is the hardest. There always seem to be more important things to do

10. Summary Error management has two components: –Error reduction and –Error containment Safety is a dynamic non-event Engineering a Safety Culture –reporting culture -> providing the data for navigation –just culture -> trust, deciding when there is fault –flexible culture -> adjust –learning culture -> plan, do, check, act If eternal vigilance is the price of freedom, then chronic unease is the price of safety