Transcript Risk Management 2007

Risk Management
2007
Historic Trends
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Based on Safety Gram data - from 1990-2006:
306 Individuals died in this 17 year period.
Leading causes of death:
Aircraft Accidents: 72 deaths, 23%
Vehicle Accidents: 71 deaths, 23%
Heart Attacks: 68 deaths, 22%
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65% of these were volunteer firefighters
Burnovers/Entrapments: 64 deaths, 21%
Historic Trends
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1990-2006 Federal - 73 deaths:
Burnovers: 39.7%
Aircraft Accidents: 19.2%
Heart Attacks: 13.7%
Vehicle Accidents: 11%
Historic Trends – Conclusions
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40% of federal fatalities were in burnovers
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Driving fatalities increased 107% from 1990
thru 1998 vs. 1999 thru 2006
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Twice the number of the next highest category,
aircraft accidents
Latter period included 3 multi-fatality driving
accidents
Heart attacks are a lesser but still
significant cause of federal firefighter
deaths
2007 Year in Review
2007 Forest Service events
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2 Forest Service fatalities
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Both driving in Region 8
one returning from incident
 one returning from training
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22 entrapped firefighters
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6 burn injuries
4 fire shelters deployed
No heart attacks
Forest Service Entrapments
2007
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Who became entrapped?
Where did these entrapments occur?
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In the WUI or elsewhere
What level of incident management was in
place when the entrapments occurred?
Who Became Entrapped
Type of Resource
Number of People
Number of events Percentage of Total
People
Entrapped
Engine Crew
Personnel
11
3
50%
Overhead
4
3
18%
Hotshot Crew
Personnel
3
1
14%
Private Citizens
2
1
9%
Dozer Operator
1
1
4.5%
Contractor
1
1
4.5%
Where Did Entrapments Occur?
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25% in WUI situations
75% outside the WUI
Level of Incident Management
2007 Entrapments
Type 1 (37.5%)
Type 2 (25%)
Type 3 (37.5%)
Recommendations
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Figure out ways to reduce driving
exposure
Emphasize use of seat belts
Emphasize proper use of PPE
Maintain fitness programs and health
screening
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Firefit
Recommendations
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Maintain emphasis on entrapment
avoidance
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Focus firefighters on operational risk
assessment
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Use case studies and STEX
But don’t develop another checklist
Engage your Incident Management Teams
Shifting Gears
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How do we know all the information just
presented?
Why should we pay attention to “near
miss” events?
What are the best ways to learn from
unintended outcomes?
Accident Pyramid
H.W. Heinrich - 1931
1
10
Serious Injury (with disability)/Fatal
Light injury (without disability)
29
Accident with losses (property/equip)
600
Incidents
Figure 3. Pyramid of Bird. Source: Geller (1998)
Current Thinking
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Managing the Unexpected – Assuring High
Performance in an Age of Complexity
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Karl Weick and Kathleen Sutcliffe
High Reliability Organizing (HRO)
Managing the Risks of Organizational Accidents
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Dr. James Reason
“Swiss Cheese Model”
Components of a ‘Safety Culture’
Current Thinking
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The Field Guide to Human Error
Investigations
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Sidney Dekker
Old view vs. new view of Human Error
High Reliability Organizing
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HROs operate in high risk environments…
…but they seem to have “less than their fair
share of accidents”
Hallmarks of an HRO
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Preoccupation with Failure
Reluctance to simplify
Sensitivity to operations
Commitment to resilience
Deference to expertise
Active versus Latent Failures (Reason, 1990)
Organizational
Factors
Latent Conditions
Excessive cost cutting
Inadequate promotion policies
Unsafe
Supervision
Latent Conditions
Deficient training program
Poor crew fitness
Preconditions
for
Unsafe Acts
Latent Conditions
Poor CRM
Mental Fatigue
Unsafe
Acts
Failed or
Absent Defenses
Active Conditions
Inadequate communications
Underestimated fire behavior
Accident & Injury
Elements of a Safety Culture
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Four critical elements:
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James Reason: Managing the Risks of Organizational Accidents
Reporting Culture
Just Culture
Flexible Culture
Learning Culture
“A Safety Culture is one that allows the boss to
hear bad news” Sidney Dekker
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Bad news has to reach the boss
What exactly counts as “bad news”?
Just Culture
A culture of justice for self-reporting errors.
An ethical workplace where people are
encouraged (even rewarded) for disclosing
errors and protected against reprisals for
normative human error … regardless of
outcome.
James Reason
Human Error
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It has been estimated that 70-80% of all
accidents involve some form of human
error
There are different types of human error:
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Decision error
Skill-based error
Perceptual error
Human Error
“Human error is a consequence not a cause.
Errors are shaped by upstream workplace
and organizational factors….. Only by
understanding the context of the error can
we hope to limit its reoccurrence”.
James Reason
Human Error and Investigations
“….unlike the tangible and quantifiable evidence
surrounding mechanical failures, the evidence
and causes of human error are generally
qualitative and elusive. Furthermore, human
factors investigative and analytical techniques
are often less refined and sophisticated than
those used to analyze mechanical and
engineering concerns.”
FAA Report: Wiegmann and Shappell
Old View of Human Error
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Human Error is a cause of accidents
To explain failure, investigations must seek
failure
They must find people’s inaccurate
assessments, wrong decisions and bad
judgments
Sidney Dekker
The “Bad Apple” Theory
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Complex systems would be fine, were it not for
the erratic behavior of some unreliable people
(bad apples) in them.
Human errors cause accidents; humans are the
dominant contributor to more than two thirds of
them.
Failures come as unpleasant surprises. Failures
are introduced to the system only through the
inherent unreliability of people.
Sidney Dekker
New View of Human Error
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Human Error is a symptom of trouble
deeper inside a system
To explain failure, do not try to find where
people went wrong
Instead, investigate how people’s
assessments and actions would have
made sense at the time, given the
circumstances that surrounded them
Sidney Dekker
New View of Human Error
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Human error is not a cause of failure. Human
error is the effect, or symptom, of deeper
trouble.
Human error is not random. It is systematically
connected to features of people’s tools, tasks
and operating environment.
Human error is not the conclusion of an
investigation. It is the starting point.
Sidney Dekker
What’s Wrong With This Picture?
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Why are reports that
cite “violations” of the
Standard Fire Orders
meaningless?
Why is the phrase “he
or she lost situation
awareness”
meaningless?
Hindsight really is perfect!
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One of the most popular ways by which
investigators assess behavior is to hold it
up against a world they now know to be
true. --Dekker
We match our hindsight of people’s
performance with a procedure or
collection of rules:
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People’s behavior was not in accordance with
standard operating procedures that were
found to be applicable to the situation
afterwards.
But we don’t learn anything….
“The problem is that these after-the-fact-worlds
may have very little in common with the actual
world that produced the behavior under
investigation. They contrast people’s behavior
against the investigator’s reality, not the reality
that surrounded the behavior in question. Thus,
micro-matching fragments of behavior with
these various standards explains nothing – it
only judges.”
--Sidney Dekker
What about “loss of situation
awareness”?
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If you lose situation awareness, what replaces
it?
There is no such thing as a mental vacuum.
The only way to “lose awareness” is to become
unconscious.
So….people didn’t lose awareness, rather the
awareness that they had differed from reality.
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Why?????
People Create Safety
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Safety is never the only goal in systems that
people operate.
Trade-offs between safety and other goals often
have to be made under uncertainty and
ambiguity.
Systems are not basically safe. People in them
have to create safety by…adapting under
pressure and acting under uncertainty.
Sidney Dekker
Doctrine and Culture
How does it all fit together?
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Rule-based Culture:
Invariably found to be in violation of own rules in the
event of an investigation
Safety programs become more restrictive and
compliance based
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Checklist saturation
Risk aversion in response to fear of liability
So What Is Doctrine?
Doctrine is the expression of fundamental
concepts and principles that guide
planning and action.
 Principles are intended to help us develop
the ability to make good choices.
 Principles need to be well stated to clearly
represent our work, the environment, and
the mission.
Foundational Doctrine Guiding Fire
Suppression
The Operational Environment
1.The Forest Service believes that no
resource or facility is worth the loss of
human life. We acknowledge that the
wildland firefighting environment is
dangerous because its complexity may
make events and circumstances difficult or
impossible to foresee. We will aggressively
and continuously manage risks toward a
goal of zero serious injuries or fatalities.
On the practical side
Doctrine provides a shared way of thinking
about problems, but does not direct how
problems will be solved.
Rules exist, but in the context of Policy, laws
and those items that are too important to
leave to discretion, interpretation, or
judgment.
On the practical side
Doctrine allows firefighters to take risk
successfully as opposed to restricting
action considered to be risky through rules
& checklists.
What is “Accountability”
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Is it the same thing as “punishment”
What types of things should people be
punished for?
What does punishment accomplish?
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“Punishing is about stifling the flow of safetyrelated information (because people do not
want to get caught)” -- Dekker
Accountability
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Accountability should be based on a well defined
distinction between acceptable and unacceptable
behavior
The determining factor is not the act, but the
intent of the actor
Evaluation based upon understanding of intent,
application of principles, and judgment
Learning and punishment don’t mix
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“A system cannot learn from failure and
punish supposedly responsible individuals
or groups at the same time.”
--Sidney Dekker
True Safety Lies in Learning
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Learning is about seeing failure as part of a
system.
Learning is about countermeasures that remove
error-producing conditions so there won’t be a
next time.
Learning is about increasing the flow of safetyrelated information.
Learning is about…the continuous improvement
that comes from firmly integrating the terrible
event in what the system knows about itself.
We all make mistakes…..
…..but how do we learn from them?
New Tools for Learning
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APA – Accident Prevention Analysis
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More formal, requires full team
Carries assurance that no administrative actions will be taken if
there was no “reckless behavior”
Written report produced that tells a story
Includes recommendations
FLA – Facilitated Learning Analysis
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Less formal, may be a 3-person team
Written report may be produced
Sand Table Exercise often produced
Does not include recommendations
SAFENET
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What SAFENET IS:
An anonymous reporting system where firefighters can
voice safety and health concerns.
Documents corrective actions taken at the field level or
provides suggested corrective actions for higher level of
action.
What SAFENET is NOT:
A forum for personal attacks/defamation.
A mechanism to elevate “pet peeves”.
Only used for incidents that need higher level corrective
action.
Interagency criteria established for posting
determination – clearly stated safety and health issue
necessary for posting.
Near Miss Reporting
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National submission decline from 2005:
2005 -- 180 submissions
2006 -- 155 submissions
2007 -- down to 119 submissions
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Every report matters!!!
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Firefighters Need a Single Handheld
Radio
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The M16 has been
the standard
infantry weapon
for U.S. forces
outside NATO since
1967.
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Medical Standards Program
SAFENET Administration
FireFit
Six Minutes for Safety
WFSTAR – Fire Safety Refresher Training
Website
Red Book lead for – Ch. 7 Safety, Ch. 18
Reviews and Investigations, portions of Ch. 13
Training & Quals, Ch. 15 Equipment
NMAC coordination
SHWT Update
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Energy, Nutrition, and Health Projects (MTDC):
Wildland Firefighter Health & Safety Reports
(publications)
Nutrition Power Point & Brochure
Shift Food Study
Hydration System Field Study
Revision of Fitness & Work Capacity
Boot Study
Powerline Safety Study
Requesting Seat Belt Study (human factors perspective)
Other studies: PPE (gloves, pants, shirts), chain saw
chaps, new Safety Zone research.
SHWT Update
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New - Incident Emergency Medical Task
Group - replaces Emergency Medical
Support Group.
Hazard Tree & Tree Felling Task Group
Injury/Illness Module in ISUITE – input
made by MEDL
Updating Agency’s Administrator Guide to
Critical Incident Management