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    This presentation is based on content presented at the 2007 Mines Safety Roadshow held in October 2007 It is made available for non-commercial use (eg toolbox meetings) subject to the condition that the PowerPoint file is not altered without permission from Resources Safety Supporting resources, such as brochures and posters, are available from Resources Safety For resources, information or clarification, please contact: [email protected]

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Toolbox presentation: Safety culture – part 1

Integrating human factors and safety management systems

October 2007

Safety culture toolbox series

1. Integrating human factors and safety management systems (Author: Bert Boquet, Embry-Riddle Aeronautical Museum) 2.

What does safety culture mean for mining?

3.

Safety culture in practice in Australian mining Department of Consumer

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Safety culture: a brief history Chernobyl, 1986 International Atomic Energy Agency noted a “Poor Safety Culture” Department of Consumer

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as a factor in the accident.

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Safety culture: a brief history King’s Cross underground fire, 1987 Thirty-one people died in the Kings Cross fire, which broke out as commuters headed home. Poor safety culture was cited as a factor.

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Safety culture: a brief history Piper Alpha, 1988 Worst ever offshore petroleum accident, during which 167 people died and a billion dollar platform was destroyed. Poor safety culture was Department of Consumer

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cited as contributing to this accident.

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 44,000 to 98,000 people in the US die each year as a result of medical error. This includes:  Wrong medications     Too much of a given drug Surgical error Infection control Misdiagnosis  In summary, human error Department of Consumer

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“There are activities in which the degree of professional skill which must be required is so high, and the potential consequences of the smallest departure from that high standard are so serious, that one failure to perform in accordance with those standards is enough to justify dismissal.” — Lord Denning Department of Consumer

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“The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.” — Dr Lucian Leape, Harvard School of Public Health Department of Consumer

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“People make errors, which leads to accidents. Accidents lead to deaths. The standard solution is to blame the people involved. If we find out who made the errors and punish them, we solve the problem, right? Wrong. The problem is seldom the fault of an individual; it is the fault of the system. Change the people without changing the system and the problems continue .” — Don Norman Department of Consumer

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Nature of blame

 Operator is seen as having control  Operator makes conscious decisions about how to carry out job  Operator has rules and procedures to follow  Organization has vested interest in blaming operator Department of Consumer

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Nature of blame

cont.

 Because people fear being “punished” for errors made on the job, minor events and mistakes go unreported  Furthermore, by focusing on the active failures, this in practice absolves organization from blame (and liability) when accidents occur Department of Consumer

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What does all of this have to do with safety?

    To improve safety, we must make better use of minor human error events Threat of corporate disciplinary action and regulatory enforcement is a major obstacle to event reporting and investigation Engineering a sound safety culture is how we go about managing human error However, nature of human error remains a problem in most systems Department of Consumer

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Effective

Intervention and Prevention Programs

Data-driven

Research Research sponsors

- FAA, DoD, NASA, & airplane manufacturers provide research funding.

- Research programs are needs-based and data driven. Interventions are therefore very effective.

Mechanical failure

- Catastrophic failures are infrequent events - When failures do occur, they are often less severe or hazardous due to effective intervention programs.

Accident investigation

- Highly sophisticated techniques and procedures - Information is objective and quantifiable - Effective at determining why the failure occurred

Accident database

- Designed around traditional categories - Variables are well-defined and causally related - Organization and structure facilitate access and use

Database analysis

- Traditional analyses are clearly outlined and readily performed.

- Frequent analyses help identify common mechanical and engineering safety issues.

Feedback

Wiegmann, D. & Shappell, S. (2001). Human error analysis of commercial aviation accidents: Application of the Human

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Aviation, Space, and Environmental Medicine,72, 1006-1016

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Ineffective

Intervention and Prevention Programs

Fad-driven

Research Research sponsors

- FAA, DoD, NASA, & Airlines provide funding for safety research programs.

- Lack of good data leads to research programs based primarily on interests and intuitions. Interventions are therefore less effective.

Human error

- Errors occur frequently and are the major cause of accidents.

- Few safety programs are effective at preventing the occurrence or consequences of these errors.

Accident investigation

- Less sophisticated techniques and procedures - Information is qualitative and illusive Focus on “what” happened but not “why” it happened

Accident database

- Not designed around any particular human error framework - Variables often ill-defined - Organization and structure difficult to understand

Database analysis

- Traditional human factors analyses are onerous due to ill-defined variables and database structures.

- Few analyses have been performed to identify underlying human factors safety issues.

Feedback

Wiegmann, D. & Shappell, S. (2001). Human error analysis of commercial aviation accidents: Application of the Human

and Employment Protection

Aviation, Space, and Environmental Medicine,72, 1006-1016

.

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Systems approach to human error management

Perhaps one of the best models for human error within an organization or a system is one proposed by James Reason: Department of Consumer

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Reason’s “Swiss-cheese” model of human error

Failed or absent defences Department of Consumer

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Adapted from Reason (1990)

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Reason’s “Swiss-cheese” model of human error

Failed or absent defences Preconditions for unsafe acts Unsafe acts

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Adapted from Reason (1990)

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Reason’s “Swiss-cheese” model of human error

Failed or absent defences Unsafe supervision Preconditions for unsafe Acts Unsafe acts

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Adapted from Reason (1990)

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Inputs

Reason’s “Swiss-cheese” model

Organizational factors Unsafe supervision

of human error

Preconditions for unsafe Acts Unsafe acts

Failed or absent defences Accident and injury

Adapted from Reason (1990)

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Applying the cheese

  In order to make full use of the systems approach, one must be willing to look beyond the active failures:    Medicine Aviation Air traffic controllers All have become very skilled at identifying active failures  Not so for latent failures Department of Consumer

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Practical implications

Study of all commercial aircraft accidents in the US 1990 –2002 The investigation used the Human Factors Analysis and Classification System to classify both active and latent failures from 1,020 National Transportation and Safety Board Accident Reports   Only 58 organizational failures were identified  Of these, most were operational processes Most surprisingly, only 46 supervisory failures were identified from the reports  The majority being inadequate supervision Department of Consumer

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Where are the latent failures?

 On the surface, the foregoing data may point to the fact that there may be relatively few latent failures in US commercial aviation  Another, more plausible, alternative is that the incidence is under-reported  If the case is one of under-reporting, then what?

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Error reporting and safety systems

 Any safety management system (SMS) is only as good as the quality and the quantity of the data (errors) that are reported  Accidents in and of themselves provide little information regarding the status of an organizations health with respect to safety  Poor error data leads to inconsistent results with respect to interventions Department of Consumer

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Violations Resources Safety 25

Intervention approaches (philosophies)

Interventions

Department of Consumer

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Intervention approaches (philosophies)

Interventions Technology/ Engineering Organizational/ Administrative Human/Crew Environment Task/Mission

Department of Consumer

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Safety Management Process

Data Hazard Identification Hazard Assessment Identify Interventions Intervention Assessment Intervention Implementation and Employment Protection

Services

Field Tool Investigator Trng HFACS Analysis Identify Vulnerabilities Focus Groups Feasibility Prioritize Identify/Develop HF Programs

Science Human Factors Analysis and Classification System ® HFIX ® Human Factors Intervention matriX

HF Consulting

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Queries

Albert (Bert) Boquet Department Chair, Human Factors and Systems College of Arts and Sciences Embry-Ruddle Aeronautical University Daytona Beach FL 32114-3900 USA  + 1 386 226 7035  [email protected]

 www.

embryriddle .edu

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