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The Error
Provocative
Environment Christopher J. Colburn, CSP, SGE
Norbord Mississippi
Goals • Define the Error Provocative Environment
• Define Safety and the Safety Vision
• Discuss Heinrich’s 88-10-2 Model
• The Non-Existent Injury Frequency / Severity
Relationship
• Speak to Fundamental Transformational Change
• This is a “KEEP IT REAL” session….
Three Frogs Sitting On a Log….
Human Behavior
Human Behavior is not Predictable
• Indicators are possible but not Scientific (Repeatable Results)
• The best indicator of future behavior is past behavior
• The big question is how do you change a behavior?
People are in most cases are like water, in that, they
will more often than not, take the path of least
resistance
• It is not, in most cases intentional, it is human nature….
DEFINE
“CULTURE” What is it?
Organizational Safety Culture “Organizational culture refers to the basic values, norms, beliefs, and practices that characterize the
functioning of an institution. At the most basic level, organizational culture defines the
assumptions that employees make as they carry out their work. It is a powerful force that can persist
through reorganizations and the change of key personnel. It can be a positive or a negative force.”
~Report of the Columbia Accident Investigation Board, August, 2003
DEFINE
“SAFETY” What is it?
Define Safety Freedom from Unacceptable Risk
(ISO Guide 51: 1999E)
What is “Acceptable Risk” in your
organization?
What is Acceptable Risk Risk Assessment Matrix
Likelihood of
OCCURAENCE
or EXPOSURE for selected
Unit of Time or Activity
Severity of Injury or Illness Consequence and Remedial Action CATASTROPHIC
Death or permanent
total disability
CRITICAL
Disability in excess of
3 months
MARGINAL
Minor injury, lost
workday accident
NEGLIGIBLE
First Aid or Minor
Medical Treatment
Frequent
Likely to Occur Repeatedly
HIGH
Operation not
permissible
HIGH
Operation not
permissible
SERIOUS
High Priority Remedial
action
MEDIUM
Take Remedial action
at appropriate time
Probable
Likely to Occur several times
HIGH
Operation not
permissible
HIGH
Operation not
permissible
SERIOUS
High Priority Remedial
action
MEDIUM
Take Remedial action
at appropriate time
Occasional
Likely to occur sometime
HIGH
Operation not
permissible
SERIOUS
High Priority Remedial
action
MEDIUM
Take Remedial action
at appropriate time
LOW
Risk Acceptable:
Remedial Action
Discretionary
Remote
Not likely to occur
SERIOUS
High Priority Remedial
action
MEDIUM
Take Remedial action
at appropriate time
MEDIUM
Take Remedial action
at appropriate time
LOW
Risk Acceptable:
Remedial Action
Discretionary
Improbable
Very unlikely – may assume
exposure will not happen
MEDIUM
Take Remedial action
at appropriate time
LOW
Risk Acceptable:
Remedial Action
Discretionary
LOW
Risk Acceptable:
Remedial Action
Discretionary
LOW
Risk Acceptable:
Remedial Action
Discretionary
What is a System? (ANSI/GEIA‐STD‐0010)
“An integrated composite of people, products, and
processes that provide a capability to satisfy a
stated need or objective.”
“The system safety concept focuses on the
application of systems engineering and
systems management to the process of
hazard, safety and risk analysis. “
Safety System The application of engineering and management principles, criteria, and techniques to achieve mishap risk as low as
reasonably practicable (to an acceptable level), within the constraints of operational effectiveness and suitability, time, and cost, throughout all phases of the system life cycle.
ALARP
ANSI/GEIA‐STD‐0010‐2009
Standard Best Practices for System Safety Program Development and Execution
MIL‐STD‐882D
Department of Defense, Standard Practice for System Safety
Fundamentals:
Acceptable Risk and ALARP Acceptable Risk
• That level of residual safety risk that the managing
authority is willing to assume on behalf of the agency,
users, and public
“As low as reasonably practicable”
That level of risk which can be further lowered only by an
increment in resource expenditure that cannot be justified
by the resulting decrement in risk Source: ANSI/GEIA‐STD‐0010‐2009
Error Provocation • The word “Provocation” means to “Provoke, Entice or
Stimulate”
• An Error Provocative Environment is an environment
that lacks controls to such a degree that the area itself
“Provokes, Entices or Stimulates” individuals to make
errors. These errors are manifested as unsafe acts.
• When an Unsafe Act and Unsafe Condition meet;
Injury Occur
Latent Conditions • Poor design,
• Gaps in supervision,
• Undetected manufacturing
defects or maintenance failures,
• Unworkable procedures,
• Clumsy automation
• Shortfalls in training
• Less than adequate tools and equipment, may be present for
many years before they combine with local circumstances and active failures to penetrate the system’s layers of defenses
James Reason,
Managing the Risks of
Organizational Accidents
How Do These Affected
Individuals View Risk?
Heinrich, H.S. Industrial Accident Prevention (McGraw‐Hill, 1959)
• 88‐10‐2 Ratios
– 88% unsafe acts of persons
– 10% unsafe mechanical or physical hazards
– 2% unpreventable accidents
• Does not consider systemic causal factors deriving from:
– Design and engineering shortcomings
– Hazards in the operational procedures
– System of expected behavior that has
developed
The Unsafe Act
The Unsafe Act
How often do incident investigations stop after addressing
the individual human error?
Other potential root causal factors:
–Organizational
–Operational
–Technical
–Cultural
The Blame Machine • Placing responsibility for the incident on what an
individual did or did not do results in overly simplistic
causal factor determination.
• In many organizations, and sometimes entire industries,
there is an unwillingness to look closely into error- provocative system faults.
R. B. Whittingham
The Blame Machine: Why Human Error Causes Accidents
Managing Maintenance Error: A Practical Guide
James Reason and Alan Hobbs
“Errors are consequences, not just causes. They are
shaped by local circumstances: by the task, the
tools and equipment and the workplace in
general. If we are to understand the significance
of these factors, we have to stand back from what
went on in the error maker’s head and consider
the nature of the system as a whole.”
Swiss Cheese Model Reason, James: “Human error: models and management”
BMJ 320:768‐770, 2000
Defining Human Error “A decision, an oversight, or a personnel action or inaction
out of which the potential arises for the occurrence of a
harmful incident or exposure.” Fred E. Manuele
“A natural consequence of a mismatch between human
capabilities and demands, and an inappropriate
organizational culture.” Guidelines for Preventing Human Error in Process Safety.
Center for Chemical Process Safety of the
American Institute of Chemical Engineers, 1994.
Design Characteristics That Increase
the Probability of Human Error
A job situation or system, which:
1. Violates operator expectations
2. Requires performance beyond what an operator can deliver
3. Induces fatigue
4. Provides inadequate facilities or information for the operator
5. Is unnecessarily difficult or unpleasant
6. Is unnecessarily dangerous
Chapanis, Alphonse. “The Error‐Provocative Situation”
in The Measurement of Safety Performance
Human Error Reduction CONCLUSION:
The solution to many, if not most, human performance
problems resulting in injury are technical in nature,
not psychological.
“Prevention through Design”
Hierarchy Of Controls 1.Elimination
2.Substitution
3.Engineering Controls
4.Warnings
5.Administrative Controls
6.Personal Protective Equipment
Rasmussen’s Drift to Danger Model
Resilience Engineering ; Erik Hollnagel, David D. Woods and Nancy Leveson; p 36, Figure 3.1
Behavioral Conclusions • Human errors, of commission or omission, are factors in
the occurrence of nearly all hazard-related incidents.
• Typical safety management systems do not address human error reduction, particularly on an anticipatory basis
• You cannot change the human condition but you can change the conditions under which people work
• The solution to most human performance problems are technical rather than psychological
Behavioral Conclusions • Potentials for human error derive largely from top-level
decisions, and the impact of those decisions spreads
throughout the organization, shaping a distinctive
corporate culture and creating error-provocative
situations
• To avoid hazard-related incidents resulting in serious
injuries, human error potentials must be addressed at
the cultural, organizational, management systems,
design, and engineering levels, and with respect to the
work methods prescribed
The Eight-Stage Process of
Creating Major Change 1. Establishing a Sense of Urgency
2. Creating the Guiding Coalition
3. Developing a Vision and Strategy
4. Communicating the Change Vision
5. Empowering Broad Based Action
6. Generating Short-Term Wins
7. Consolidating Gains and Producing more Change
8. Anchoring New Approaches in Culture
Four States of Organizational Culture
1) The ability to rebuild after a failure has occurred. This implies
that we hope we will not fail, or in terms of safety, that we will not have a catastrophic mishap or serious injury, but if we do we will recover and move on
2) Expecting failure to occur and devising ways to limit the effects of this failure so the organization can rebound or recover from failure states in a graceful manner. This allows the preservation of the core capabilities of the system so the organization can continue to operate even in a degraded stated
Four States of Organizational Culture
3) Building the capacity of a system to handle perturbations or disruptions outside of those it was designed to handle. This implies that to be resilient an organization must be able to react and adapt to the unexpected without catastrophic failure
4) Protecting the core processes to maintain stability while encouraging the ability to adapt to changing environments, which will in turn function to preserve the core processes through change management. This idea of resilience seems to imply that it can be used to help organizations stand the test of time despite external pressures and “weather the storm” during climates of change
E4 Approach
Education + Engagement
+ Empowerment =
Excellence
Questions
• Resilience engineering needs
to provide organizations with help on how
to decide when to relax production pressure to reduce risk.
Resilience Engineering ; Erik Hollnagel, David D. Woods and Nancy Leveson; p 32
Quotes
“ In Theory, Theory and Practice are the Same; In
Practice, They are not….”
~ Yogi Berra
Perfection is not attainable, but if we chase perfection we can catch
excellence.
~ Vince Lombardi
Engagement + Empowerment = Excellence
~ Christopher J. Colburn
Christopher J. Colburn, CSP. SGE
Norbord Mississippi
Safety and Training Manager
