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Humans and Machines: the Hidden and Not So Hidden
Hazards
Alan D. Quilley CRSP
Session Description
The human/machine interface is much more important to Health & Safety Management than just Ergonomics. Human behaviours and thinking, about and around machines can, and does, cause serious problems. High energy machinery does significant damage when that energy comes into contact with the very vulnerable human body. Using the Energy/Barriers model of Incident Causation married with our knowledge of human thinking and behaviour can assist us in our hazard evaluation and control.
The Journey
The Journey We’ll Take
• Where we’ve been
• Where we are
• Where we should/could be going
Outline
• The Journey
• The History
• The Current Challenges & Knowledge
• Thinking & Attitude
• Culture & Behaviour
• Energy / Barriers Model
• Hazard Recognition, Evaluation & Control
• The Future
• The To Do List – Practical & Actionable Items
The History
Early Attempts
• Don’t Touch the Spinney Thing
• Tell workers it’s their fault so “BE CAREFUL!”
• Soften the Blow of High Energy Thru Barriers &
PPE
A Bit of History• Blame the Worker
• Blame the System
• Inputs Create Outputs - Deming
• Continual Improvement
• Blame the Behaviour
• Target Zero – Hoping for Perfection
• True Integration
• Safe Production
Petersen’s
Accident Theory
Overload
• Pressure
• Fatigue
• Motivation
• Drugs/Alcohol
• Worry
Ergonomic Traps
• Incompatible workstation
• Incompatible expectations
Decision to Err
• Misjudgement of risk
• Unconscious desire to Err
• Logical decision based on the situation
Human Error
Energy Release/Accident
Injury/Damage
Systems Failure
• Policy
• Responsibility
• Training
• Inspection
• Correction
• Standards
Proactive
MeasuresRisk Analysis
• Recognition
• Evaluation
• Control
Analysis
AdjustmentInvestigation
• Preventive Measures
• Reporting
• Follow-up
Incident
Anticipation Reaction
Continuous
Improvement
Loop
Pre Incident Post Incident
What Could Happen What did happen
Near Miss Reporting Incident Reporting
Management System Components Incident Investigation Program
Model of Managing for Outstanding Safety
Management
Vision,
Commitment
& Drive
Safe
Equipment &
Physical
Environment
Safety Aware,
Trained &
Committed
Workforce
Outstanding
Safety
Performance
The Essential
CornerstoneMain Drivers
The Workplace
OutcomesThe Result
Line Ownership
of Safety
Involvement in
Safety Activities &
Training
Comprehensive
Safety Systems
& Practices
Safety
Organization
and Specialists
J.M. Stewart “Managing for World Class Safety”
Measurable
Intention
Measurable
Execution
Measurable
Outcomes
Measurable
Indicators
Integrated Safety Management System
Company CultureMission, Vision & Values – Commitment
of Time & Money
Safe BehaviourStandards, Practices
& Procedures
AccountabilityActivities, Measurements
& Rewards
Safe EnvironmentTools, Equipment, Materials, Environment
Encourage
Engage
Evolve
Evidence-Based
Tools
The Current Challenges & Knowledge
Thinking & Attitude
Anyone See A Problem WithRISK & “Power of Positive Thinking?”
I Think I Can, I Think I Can, I Think..
Some Thoughts On How We Think…
Dr. Daniel Kahneman labels:
• Approximately 95% of the mind that is unconscious
`System 1’;
• Approximately 5% of the mind that is conscious
`System 2’.
“System 1 operates automatically
and quickly, with little or no effort and
no sense of voluntary control.
System 2 allocates attention in the
effortful mental activities that demand
it. The operations of System 2 are
often associated with the subjective
experience of agency, choice, and
concentration.
• System 1 as a “machine for
jumping to conclusions”
• System 1 is “gullible and biased
to believe”
• System 2 is in charge of doubting
and unbelieving
• System 2 is sometimes busy, and
often lazy.”
What You See Is All There Is(WYSIATI)
“What You See Is All There Is”
WYSIATI
“We can't see what we can't see
no matter how hard we try to
make that untrue.”
See The Panda?Don’t Tell!
Once You See It… You Can’t Un-see
It!
See The Panda?
Classic Risk Management
This is demanding System 2
Thinking from predominantly
System 1 Thinking humans.
What could possible go wrong?
WYSIATI
The REAL Challenge Becomes A Serious Reduction Of
“Think Time”
To: You
From: Me
Subject: Info You Owe Me
Well?????
Mr. Urgent
Culture & Behaviour
Integrated Safety Management System
Company CultureMission, Vision & Values – Commitment
of Time & Money
Safe BehaviourStandards, Practices
& Procedures
AccountabilityActivities, Measurements
& Rewards
Safe EnvironmentTools, Equipment, Materials, Environment
Encourage
Engage
Evolve
Evidence-Based
Tools
Knowing Isn’t Enough
Pros & Cons
Attitude
“Thinking”
Behaviour
“Doing”
Attitude & Behaviour
“Thinking & Doing”
Integrated Safety Management System
Company CultureMission, Vision & Values – Commitment
of Time & Money
Safe BehaviourStandards, Practices
& Procedures
AccountabilityActivities, Measurements
& Rewards
Safe EnvironmentTools, Equipment, Materials, Environment
Encourage
Engage
Evolve
Evidence-Based
Tools
Culture
Culture
“How a group of people behave habitually”
More simply put, it’s just…
100%Compliance ?
The Way It Is Around Here…
We Wear DifferentPPE on the Weekend!
Company Culture
•What You Say• Mission, Vision, Values, Policies & Statements of
Commitment
•What You Do• How You Demonstrate You Mean What You Say
• How You Allocate Your Resources – Time & Money
“Human Error Is NaturalAnd A Very Real Possibility”
“Drawing attention to incidents helps to raise awareness and enables
employees to change their behaviour, so that the probability of an incident
recurring is reduced,”
“Talking about risk helps to reduce it,”
“If a colleague tells you there’s an ice patch
on which you almost fell, you’ll avoid it.”
http://sea-globe.com/human-error/
Making Safety Personal- Tell Stories
Risk Compensation Theory
People typically approach an action or
behaviour based upon
the perceived risk involved.
Example: When Sweden changed from driving on the
left-hand side of the road to the right in 1967 there was
a demonstrable reduction in traffic accidents over the
following 18 months, before returning to normal.
Drivers drove more carefully during those 18 months
because the perceived risks were greater, and it is
hypothesised that the reverse was also true: people
drove less carefully when the perceived risks were
reduced.
Build A Culture Of Story Telling
Not filling in forms!!!!
Remember: What gets measured...gets done.
What gets rewarded…gets results
Behaviour
BBS By Another Name!
• Safety Management System
• Behaviour Based Safety - ABCs
• Transformational Safety
• Safety Differently
• Safety II
• Bradley Curve - Interdependent
• Integrated Safety Management
• Making Safety Personal
Behaviour
Activator/AntecedentWhat happens to motivate the behaviour
BehaviourThe action(s) taken by the person
ConsequencesWhat results from the behaviour
Behaviour Is About Consequences
“ People do what they do because of what happens when they do it. ”
Aubrey C. Daniels
Example: “Company Policy: Starting Tomorrow You’ll Wear A Seatbelt!”
• Does/Did your attitude change?
• Does/Did your behaviour change?
• Why do/did we change? Immediately or Slowly?
• What happens if you did or didn’t comply?
• How do/did you develop the new behaviour/attitude?
The Real Issue Is Behavioural
• Behaviour Change WORKS
• Attitude Change and Changing System 1 to System 2 Thinking MAY work but NOT without turning it into a “Behavioural Initiative.”
• Remember - 95% of human thinking is likely System 1 –for a reason.
• Wishing it to be different doesn’t change a thing.
How Do We Get HIGHCompliance Rates
With Critical Behaviours?
Habits
The Power of Habit
Cross your arms…
The Power of Habit
Cross your arms…
Now do it the other way
What Would It TakeTo Make It a Habit?
Make Safety Personal&
Make It a Habit!
Much More Likely to Succeed
Over 100 years of Human
Psychology Research Have
Taught Us the ABCs of
Human Behaviour
Safe Behaviour…
Is Managed By Providing
Activators & Consequences
Habitual Safety Behaviour is Powerful
Lessons Learned• Use System 2 Thinking before “The Heat of Battle.”
• Make Safety as “Easy as Possible”
• Make Safety A Habit – If it feels uncomfortable to do it wrong You’ve succeeded!
• Supply and Manage Activators
• Give Consequences to Motivate Critical Behaviours
• Rules (Activators) without an ABC implementation plan aren’t very powerful
• Always Remember “What happens if they do…what happens if they don’t?”
Behavioral ConsequencesAubrey Daniels – “Bringing out the Best in People”
4. PENALTY (P-)
Energy / Barriers Model
Safety #101
Energy/Barriers Model
Energy
Source Path
B
A
R
R
I
E
R
Protected
Person or
Thing
B
A
R
R
I
E
R
Types of Energies
• Mechanical Energy
• Electrical Energy
• Chemical Energy
• Kinetic Energy (Moving Objects)
• Potential (Stored) Energy
• Thermal Energy
• Acoustic Energy
• Radiant Energy
• Biological Hazards
• Atmospheric/Geological/Oceanographic
Barrier System Types
• Physical, material– Obstructions, hindrances, ...
• Functional– Mechanical (interlocks)
– Logical, spatial, temporal
• Symbolic– Signs & signals
– Procedures
– Interface design
• Immaterial– Rules, laws, principles
– Ten Commandments, Laws of Robotics
General Barriers
Culture
– The Way It Is Around Here
– Where We Spend Our Resources
Accountability
– Who’s Responsible & How Do We Measure?
Environment
– Tools, Equipment, Environment, Materials
Behaviour
– ABC Analysis
– Training
Specific Barriers
• Eyes – safety glasses
• Face – face shields
• Head – hard hats
• Ears – earplugs / earmuffs
• Limb / body – aprons / chemical resistant coveralls / chainsaw chaps, etc
• Feet – steel toed & shanked boots / rubber boots
• Hands – gloves, latex / vinyl / neoprene / cut resistant
• Respiratory – dust masks / purifying respirators / SCBA , etc
• Fall Protection – body belts / full body harnesses / lanyards
Hazard Recognition, Evaluation & Control
Three Step Process
1) Hazard Recognition
2) Hazard Evaluation
3) Hazard Control
Hazards and Incidents
• A hazard can be defined as:• any condition or circumstance that has the potential to cause
injury, illness, disease or damage to property and equipment.
• An incident can be defined as:• an unplanned event which could or does result in damage, injury
or illness.
Risk & Energy
The Unseen WYSIATI
• False feedback feeds System 1 thinking – I’ve Done It Before…
• Shared experiences and skeptical thinking feeds System 2
• Imperfect Human meets Imperfect Machines in an Imperfect Environment using an Imperfect Process… What could possibly go wrong?
The Hierarchy of Control Measures
Eliminate
Substitute
Engineering Controls
Administrative Controls
Personal Protective Equipment
Most Effective
Least Effective
Control the Energy
Energy
Source Path
B
A
R
R
I
E
R
S
Protected
Person or
Thing
B
A
R
R
I
E
R
S
The Future
What’s The Immediate Future Hold?
• Stop Demanding Perfection From Imperfection
• Make Safety Creation Personal Through Engagement
• Increase Story Telling – Enhance Honesty Through Culture of Trust
• Less Reliance on “The Records” and More on the Risk Sharing
What’s The Immediate Future Hold?
• Engage Everyone in Thinking & Behaviour Safety
• Further Develop Highly Reliable Systems & Machines/Equipment
• Continual Improvement is Our Only Plannable Future
• Questions? Comments?
Try To Keep Up!
The real “ART” is
to learn how to
FILTER
The Long Term Future?
The prospect of automation taking away human jobs is both alarming and an opportunity to reorient our civilization to new objectives. The worrying part is that a sizable number of jobs, both blue and white collar, might be gone soon - a number that some estimates put as high as 47% during the next 25 years.
http://bigthink.com
Human error contributes to
accidents in 90% of cases.
It is either the driver of the truck or the
other road user that makes the
mistake that contributes to the
accident.
European Accident Researchand Safety Report 2013
2.2.3 Human factors
Human error contributes to accidents in 90% of cases. It is either the driver of the truck or
the other road user that makes the mistake that contributes to the accident. The main problem
areas identified in accidents where the truck driver was the cause of the accident are:
• Inattention (Section 4.5).
• Misjudgement of speed, causing instability and resulting in a rollover in a bend, jackknifing when
braking or swinging out on a slippery road.
• Misjudgement of the risk in a particular traffic situation.
The two most common human factors that contribute to accidents involving heavy trucks are
“Failure to look properly” and “Failure to judge another road user’s path or speed.”
The fact that such a high proportion of accidents are in whole or in part caused by human error
shows the great need for driver support systems that can help drivers to better negotiate
today’s complex traffic situations.
European Accident Researchand Safety Report 2013
Is Automation A Key Problem Solver?
Let’s Check…Driverless Car, Train, Plane?
Trust the Automation?
https://www.cnbc.com/2017/08/30/pilotless-airplanes-are-more-attractive-to-some-types-of-flyers-.html
Would you get on a pilotless plane?
• Men more likely than women to get on a plane with no pilot.
• Cheaper tickets not seen as a worthy incentive.
• Only one in five across whole survey would trust pilotless plane.
• People aged between 18 and 34 who held higher levels of
education were more likely to step on to a remote controlled
aircraft.
Likely Increases In Our World…
• More Automation
• More Nano-technology
• Faster Computing and Communicating
• More Information to Process
• More Powerful Machines
• Greater Sense of Urgency
• More Distracted Humans
• More Knowledge About How We Think & Behave
The To Do ListPractical & Actionable Items
Use What We Know
• We know a fair amount how Humans think
• We know high energy creates severe outcomes
• We know a great deal about human behaviour
• We know how to develop habits
• We can become habitual risk managers with some knowledge, training and practice.
• By the way…unfortunately it’s highly unlikely we’ll ever be perfect.
Some are suggesting that humans
need to be Chronically Uneasy to
manage Risk.
I would suggest this flies in the face
of what we know about humans and
how we think. Read: IMPOSSIBLE
What is possible is to be Selectively
Uneasy about High Energy/Human
interactions and to habitualize what
we do about those situation.
Health & SafetyShared Experiences Platform
“Those who cannot remember the
past are condemned to repeat it.”
- George Santayana
1863 - 1952
Common Themes
• Excavations
• Contact With Machinery
• Lifting Operations
• Road Traffic / Transportation
• Utility Hits
• Fires / Explosions
• Work At Heights
• Lock Out
• Dropped Objects
• Compressed Gas
• Manual Handling
• Weather Conditions
• Slips / Trips / Falls
• Hand Tools
What We Can Expect…
Leading Indicators Of Safety
0
10
20
30
40
50
60
70
80
90
100
May June July Aug Sept Oct Nov Dec
% S
afe
Be
ha
vio
urs
Last Two Quarter
Measure The Right Things…Get Results
Vehicle Damage IncidentsDropped Over 46%
to Low Single Digits Annually
Trailing Indicators
Year 2005 2006 2007 2008
Major 6 1 4 1
Serious 101 64 33 13
Percentage Reduction -37% -48% -61%
0
20
40
60
80
100
2005 2006 2007 2008
Nu
mb
er
of
Inc
ide
nts
Year
Serious
Major
Field Operations
The Steps – Make THIS A Habit!
1. Identify the Energy
2. Think & Talk Through the Energy/Barriers Model
3. Decide What Barriers Make Sense For The Hazard/Operations
4. Select Critical Behaviours
5. Manage Activators & Consequences
6. Measure (Inputs & Outputs)
7. Adjust & Refine
8. Celebrate or Correct
Thank You For Your DedicationIn Helping Make Workplaces Healthy & Safe
