1. Should We Manage Safety Differently? CORPORATE SAFETY CONFERENCE AUGUST 12, 2015

2. Discussion Points  Our current view of Safety  Let’s define safety differently  Talk of human error  Levels of Failure  Pre-Accident Investigation  Final Thoughts

3. Our Present View

4. The Three Parts of Every Failure The ContextThe ConsequenceThe Retrospective Understanding 1 1 2 2 3 3 4 4

5. Two courses of action are typically pursued Fix the Worker (Training, Discipline, or Termination) Fix the System (May take longer to fix, cost money)

6. You may recognize this….

7. Measurement focuses on incidents Successful Safety Program Absence of Accidents LTIR TCIR DART Near Misses We count the people we hurt, and totally discount all the employees we are keeping safe.

8. We must change the way we manage safety or order to align our organizations and operations to a new definition of what “safe” is, and why it matters

9. It begins with how we define “Safety” Traditional Approach Let’s Change our Definition The state of being safe; freedom from the occurrence or risk of injury, danger, or loss Safety is not the absence of events, Safety is the presence of defenses

10. Human Error

11. ‘People Make Errors’  Errors are noticed if there is some type of outcome or consequence that is significant enough to be noticed  Errors are simply the unintentional deviation from an expected behavior  They occur everywhere, and there is nothing you can do to avoid them  It is how people are wired, how we are made, a natural part of being human  You can’t punish away errors, and you can’t reward it away either

12. Systemic Issues Cause Human Error We need to understand why it made sense for them to do what they did Explore and identify symptoms of trouble deeper inside the system Address the gaps between how work is imagined (in rules) and how it is done (in practice)

13. What can we learn from the auto industry How many fatal highway accidents occur per year on average? A. 5,000 B. 10,000 C. 20,000 D. 30,000 Answer….30,000

14. “Change everything but the driver”  Tire pressure monitoring  Adaptive Cruise Control/collision mitigation  Blind spot detection/side assist  Lane departure warning  Rollover prevention/mitigation  Occupant –sensitive/ dual stage airbags  Emergency brake assist / collision mitigation  Adaptive headlights an/or night vision assist  Rearview camera  Emergency response

15. “Let’s fix the worker!”  In many instances, we try to get safety performance by “leaving everything the same except fixing the employee”  We rarely fix the system around the employee  No one person has the power to stop all accidents in the workplace  We must build systems to allow workers to fail safer. Start thinking like the car industry

16. Recognize this ship?

17. How about a hint?

18. What was the failure of the Titanic? Or

19. “The Practically Unsinkable Ship” 1.Traveling through known iceberg area 2.Watertight bulkheads – that weren’t exactly watertight 3.Crows Nest (Lookout) – did not have binoculars 4.Crew had a total of 6-hours of sea trials 5.Some exits were locked to keep the lower class passengers below deck 6.Fitted with only 20 lifeboats (3 different types) 7.Iceberg report given to Capt. Smith 8.Marconi wireless radio – used to transmit passenger messages 9.Distress Calls …..so the story and failure of the Titanic was more than an iceberg, or captain Let’s review the multilayered failures…

20. Reducing failure relies on a system focus, making integrated changes to processes and practices

21. Identifying Pre-Accidents Tasks you know will cause consequences if these process fail Looking at the process and saying :when this process fails what safety defenses will reduce and control the consequences We must assume failure will happen Look for high consequence activities

22. Identifying Pre-Accidents Errors, near misses, close calls – any of these factors could indicate problems Monitor low level events – systems that can be confusing, conflicting, or flawed Small events allow us to take the “pulse” of our processes and systems Look for small signals that can indicate system weaknesses within the normal work process

23. Identifying Pre-Accidents Look for cases where if the worker were to follow the process, the worker would fail Where we place workers in positions of uncertainty, while we assume there is clarity Review job instructions, training, JHA’s Look for error provoking system steps and processes

24. Identifying Pre-Accidents Ask your employees where the next accident will happen – you’ll be surprised to what you learn Your employees know where your system makes sense, works well, and is efficient Don’t defend the process over the opinion of the employee Listen to your employees

25. Identifying Pre-Accidents You’re not ever going to be able to stop an accident – but we can change how it affects the organization Pre-accident investigations help us be better prepared for failure The only tool you have to prevent events from happening is your organizations ability to learn Engage and strengthen your system against potential failures

26. Final Thoughts…. 1. Be fixated on where the next failure will happen – Like all good organizations. Good companies don’t want to be surprised 2.Strive to reduce complicated operations – Ask ourselves if this operational complication make work easier to do? Or is this complicated system serving some part of the organization other than the worker? 3.Respond to low level signals seriously – We collect near miss and close call information, let’s make sure we act. They are a function of how much our workers trust us and our organizations 4. Respond to events deliberately - Don’t get emotional, don’t go out and fix the worker, don’t enact immediate policy and rule change. Slow down and learn. 5.Change how we measure safety – Focus on looking for the presence of positive capacities in people, teams, and organization.