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

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

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

4. 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

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

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

7. Ask How
Not Why!
The
Curious
Organization
Conklin/Railey

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

9. 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

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

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

12. 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

13. 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

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

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

16. 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

17. 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

18. 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

19. 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

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

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

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

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

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

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

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

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

28. 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

29. 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

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