1. © Baines Simmons Limited 2004 One small step for management one giant leap for error management Keven Baines Director of Baines Simmons Limited

2. © Baines Simmons Limited 2004 The conference objective To provide information and ideas on "best practice" with respect to training approaches, methods, techniques, tools and subject matter. My presentation objectives How you really make it work By reviewing our experience of the last two years

3. © Baines Simmons Limited 2004 What we know… The spread of contributing factors is not concentrated at the active failure end or the man with the spanner Accident causation is not simply restricted to active human failure: 1.Organisational processes-27.8% 2.Local working conditions-20.9% 3.Latent Failures-19.6% 4.Defences-19.6% 5.Active failures-12.2% David G.P. Stephens 1996

4. © Baines Simmons Limited 2004 “Just give the HF training to my spanner turners’ and the problem will go away at minimal cost to the business...” But we routinely hear…

5. © Baines Simmons Limited 2004 What we (almost) never hear is “Our senior management team to really need to understand what this (required) programme could do for us before we do any staff training”

6. © Baines Simmons Limited 2004 Hands-on staff perceptions The most commonly voiced concern we hear from production, supervisory and support staff (during their HF/EMS training course) is…The most commonly voiced concern we hear from production, supervisory and support staff (during their HF/EMS training course) is… “this is all very interesting, and yes at last we are discussing what its really like out their in the workshop, hangar or line…but how much training has our management team had on this”?“this is all very interesting, and yes at last we are discussing what its really like out their in the workshop, hangar or line…but how much training has our management team had on this”? Our answer is…Our answer is… If we have the order right a senior manager already opened the course and said this himselfIf we have the order right a senior manager already opened the course and said this himself Staff should be shown how they can effect change in the systemStaff should be shown how they can effect change in the system They should be shown how the error management system works and the part they are expected to playThey should be shown how the error management system works and the part they are expected to play

7. © Baines Simmons Limited 2004 We all know that there is an ideal order of roll-out We visit many organisations who are putting all their immediate efforts in the wrong placeWe visit many organisations who are putting all their immediate efforts in the wrong place Staff training is the largest cost of compliance so the amount of effort expended is biggestStaff training is the largest cost of compliance so the amount of effort expended is biggest We have seen that to be successful:We have seen that to be successful: 1.You must first be management team focussed 2.The training cannot exist outside an error management system

8. © Baines Simmons Limited 2004 Human Factors training can only be successful within an error management system Staff HF/EM Initial Training Just culture / disciplinary policy & safety culture Error/Contributing Factor Data analysis Your existing QA system/ Continuous Improvement process Maintenance Error/Hazard Reporting system Maintenance Error investigation using trained investigators Notification of bad data to the author Management training TNA + cultural assessment Fatigue management Incomplete task/shift handover Drafting good procedures Planning wrt HF…etc. Recurrent HF/EM training & continuous feedback to staff Pictures with permission of Baines Simmons Limited © 2004

9. © Baines Simmons Limited 2004 Changing perceptions Again a common problemAgain a common problem Sometimes due to the fact that this HF thing has been around since the early ninetiesSometimes due to the fact that this HF thing has been around since the early nineties The management team will undoubtedly have formed a mental model of what this Human Factors thing is all about.The management team will undoubtedly have formed a mental model of what this Human Factors thing is all about. It is one of the most difficult things that we have to overcome, before we can move forwards.It is one of the most difficult things that we have to overcome, before we can move forwards. But we have a solution…and its from the regulatorBut we have a solution…and its from the regulator

10. © Baines Simmons Limited 2004 The Golden opportunity What should this vital manager’s session cover?What should this vital manager’s session cover? Break their misconceptions - communicate what this programme is really all aboutBreak their misconceptions - communicate what this programme is really all about An especially difficult task if the company has past (incomplete) experience of partial HF programmeAn especially difficult task if the company has past (incomplete) experience of partial HF programme Start small and build on it…wet their appetites…leave them wanting moreStart small and build on it…wet their appetites…leave them wanting more

11. © Baines Simmons Limited 2004 Who should attended? Who are your key managers? Not always status, possibly influence…Who are your key managers? Not always status, possibly influence… How vital do you consider his/her attendance?How vital do you consider his/her attendance? Training session only goes ahead if these key people are in attendanceTraining session only goes ahead if these key people are in attendance What managers?What managers?

12. © Baines Simmons Limited 2004 How do you affect managers attitudes? 1.Managers TNA, one objective: Getting buy-in 2.Light on Human Factors – heavy on organisational culture 3.Get them to list risks to the business in their groups – let them talk 4.Demonstrate how the error management system (which includes HF training) will help mitigate those risks 5.Ensure that they leave with a clear understanding that error lives in us all, not just a few isolated poor performers… 6.Ensure its about their company…

13. © Baines Simmons Limited 2004 “But we don’t have a problem example here”…

14. © Baines Simmons Limited 2004 “We don’t think we have procedure compliance problems”

15. © Baines Simmons Limited 2004 How do you affect managers attitudes? 8.They should leave wanting an error management system, because its good for business. 9.Create a common language regarding error/violation/system induced etc… 10.Ensure that they go away hungry to see the error budget 11.Get the whole top team together - away from the facility (this is never going to happen, but aiming high means settling somewhere in the middle) 12.Real success examples

16. © Baines Simmons Limited 2004 What is the ultimate prize? If you achieve these 12 training objectives during the senior team session you might just result in a pull approach to your error management problemIf you achieve these 12 training objectives during the senior team session you might just result in a pull approach to your error management problem management team will fully understand what they have really committed to in the safety and quality policy…management team will fully understand what they have really committed to in the safety and quality policy… They won’t want to tick the box…one size fits all approach to the human factors and error management trainingThey won’t want to tick the box…one size fits all approach to the human factors and error management training

17. © Baines Simmons Limited 2004 we always cover: Business risks – they know what they are, just ask themBusiness risks – they know what they are, just ask them How big is your companies Error Iceberg – they don’t know this, but they will have a good guessHow big is your companies Error Iceberg – they don’t know this, but they will have a good guess Who owns your error budget – nobody does, so make them squirmWho owns your error budget – nobody does, so make them squirm Return on Investment – they will ‘get’ this without too much help from youReturn on Investment – they will ‘get’ this without too much help from you Organisational culture – SHoMe or similar, make them see the truth from the iceberg of ingoranceOrganisational culture – SHoMe or similar, make them see the truth from the iceberg of ingorance How your EM programme will reduce your business risks – by now they are putty in your handsHow your EM programme will reduce your business risks – by now they are putty in your hands Success stories – ask…go and see…and recount – now they are running out the door hunting for error!Success stories – ask…go and see…and recount – now they are running out the door hunting for error!

18. © Baines Simmons Limited 2004 Summary - how to ensure your HF training delivers 1.Start with management team training – golden opportunity 2.Your HF training must exist within an error management programme - alone it will cost the same and fail to return on your investment