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Todd Conklin PhDHuman Performance Improvement
High [email protected]
Pre-Accident
Investigation
Conklin
Never
take a sleeping pill
And a laxative
at the same time.
In any order…
Conklin
Safety is not
the absence of
failures.
Safety is the
presence of
defenses.
Conklin
ConklinConklin
Until They’re NOT..
*
“ To understand
failure…we must first
understand our
reaction to failure.”
— Sidney Dekker
Conklin
3 Parts of an Event
Conklin
Pre-Accident Investigations – Conklin 2012
*
Conklin
We Must Manage
Behavior and
Work ProcessesIn Parallel…
Workers are
People…
Workers are
not Machines.
Conklin
Worker’s Don’t Cause
Failures.
Worker’s Trigger Latent
Conditions That Lie
Dormant In Organizations
Waiting for This Specific
Moment In Time.
People
Make
Mistakes…
(All the time)
Conklin
Human
Error
Expertise
Identification
Exercise
Conklin
13
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.
Conklin
*
“Mistakes arise directly from
the way the mind handles
information, not through
stupidity or carelessness.”
-Edward de Bono PhD
Conklin
Error is not a choice.
Mistakes
Violations
=
Conklin
Make it easyto talk about
conditions
that are wrong
Conklin
1
Shift your
thinking from
“Why”
to “How”
Conklin
Workers fail when
they find themselves
in situations where it
is easy to get hurt
and hard to be safe.
Conklin
A reliable
organization can
spot an action
going wrong…not
Wait for an action
gone wrong.
Start
Of
Job
Hazard
Event
Normal
WorkPre-
Accident
Learning:
Safety Understood:
Drift and Accumulation
Conklin
Workers
Are Masters of
Complex Adaptive
Behavior…
Conklin
*
Clearly Safe
to do Work
Clearly Not Safe
to do Work
The Gray Area:
Uncertain
interpretation
of Safe work
Conklin
23
*
Clearly Safe
to do Work
Clearly Not Safe
to do Work
Event
Conklin
Atte
ntio
n To
T
ask
Familiarity With Task
Automatic
Hi
Hi
If - Then
Patterns
1/10,000
Inattention
1/1000
Misinterpretation
1/2
Mental Picture
Performance Modes
Conklin
Translated from Jens RasmussenHuman Errors: A Taxonomy for Describing
Human Malfunction in Industrial Instillations
Swarm
in the right
people
Learn and Fix
Conklin
2
Knowing less
Does not make
You smarter.…or safer.
All Event
prevention
happens through
Learning
Conklin
You cannot
Learn and
Perform at the
Same Time.
The Problem
Conklin
The story of
all the little
events….
Collectively
tells you
where the
next event
may happen.
Conklin
Conklin
If you want to know
how work is done…
Ask a worker.
Conklin
When you investigate an event
and the workers is not
involved…You’re talking
about the worker.
When the worker is involved…
your talking with the worker.
Is the juiceworth the
squeeze?
Conklin
Behavior is the
product of your
Organizational
System
Conklin
1. Choose and number between 1 and 10
2. Multiply that number by 9
3. Add the two digits of this number together
4. Subtract 5 from this new number
5. Translate this number to a letter – 1 = A, 2 = B…
6. With this letter – choose a country that starts with
that selected letter
7. With the last letter of this country – choose an
animal
8. With the last letter of this animal – choose a fruit
Conklin
Denmark
Kangaroo
Orange
Solution Space
The Power of
Early
Hazard
ID
Identified
or Discovered
Problem
Conklin
Solution SpaceThe Power of
Early
Hazard
ID
Conklin
Learn
beforeActing
Conklin
1. Make it easy to see
conditions that are wrong.
2. …Swarm in and Learn and
Fix.
3. Spread the news across the
Site.
4. Leave the capacity for the
people to do it again –
themselves.
Conklin
Safety is not the
absence of
failures.
Safety is the
presence of
defenses.
Conklin
Safety is the
freedom from
unacceptable
risk.
Conklin
Want to think
more?
Try This
Book…
Conklin
