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Humans, Error, and Organizations

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Humans, Error, and Organizations The Socio-Technical Relationship That Drives Our Understanding of (and subsequent reaction to ) Organizational Failure. – PowerPoint PPT presentation

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Title: Humans, Error, and Organizations


1
Humans, Error, and Organizations
  • The Socio-Technical Relationship That Drives Our
    Understanding of
  • (and subsequent reaction to)
  • Organizational Failure.
  • Todd Conklin, Ph.D.
  • Safety Improvements Initiative Office
  • Los Alamos National Laboratory

2
The Law of Unintended Consequences
  • Never take a sleeping pill and a laxative at the
    same time

3
Remember
  • Never remove a safety barrier that has dents in
    it.

4
Safety Redefined
  • Safety is not the absence of accidents
  • Safety is the presence of defenses in your
    processes, procedures, and methods.
  • In short
  • What we do for a living is keep failure from
    being successful.

5
In my observation
  • People are as safe as they need to be, without
    being overly-safe, in order to be efficient.

6
When Good Pets Go Bad
7
Human Performance
  • To understand failurewe must first understand
    our reaction to failure.
  • People do not operate in a vacuum, where they
    can decide and act all-powerfully. To err or not
    to err is not a choice. Instead, peoples work
    is subject to and constrained by multiple
    factors.
  • Sidney Dekker

8
Think About This
  • Workers dont cause events.
  • Workers trigger latent conditions that exist in
    systems, processes, procedures, and expectations
    that always lie dormant on the job-site.

9
Murphys Law Revisited
  • Anything that can go wrong.
  • Probably wont.

10
Accident Defined An Unexpected Combination of
Normal Variability
  • We must strive to understand that accidents dont
    happen because people gamble and lose.
  • Accidents happen because
  • the person believes that what is about to happen
    is not possible
  • or what is about to happen has no connection to
    what they are doing
  • or, that the possibility of getting the intended
    outcome is well worth whatever risk there is.

11
The Individual
  • People are fallible, and even
  • the best make mistakes.
  • and your best people are out there making
    mistakes right now

12
Origins of Human Error
13
Exercise
  • 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.
14
Limitations of Human Nature
  • Errors arise directly from the way the mind
    handles information, not through stupidity or
    carelessness.
  • Dr. Edward de Bono

15
Old vs. New View of Human Error
  • Human error is a cause of accidents
  • To explain failure, investigations must seek
    failure
  • They must find peoples inaccurate assessments,
    wrong decisions and bad judgments
  • Human error is a symptom of trouble deeper inside
    a system
  • To explain failure, do not try to find where
    people went wrong.
  • Instead, find how peoples assessments and
    actions made sense at the time, given the
    circumstances that surrounded them.

16
On Error
  • Identified error without consequence is a good
    thing.
  • Error occurs often enough to expose weaknesses
    in defenses, organizational processes,
    procedures, and the culture.

17
Consequence Creates Error
  • The Central Dilemma is..
  • The organization wants to know everything that
    goes onbut
  • The organization cannot accept everything that
    goes on. The thought that events can just
    happen is unacceptable to the organizations
    understanding of itself.

18
Error is Often Attributed
  • Errors exist independently of our looking for
    errors
  • Your perspective, by definition, does not allow
    you to see the workers perspective.
  • The determination that a worker made an error is
    a judgment that is passed organizationally from
    you to the workers decisions.

19
To err is human
To deviate is also human
  • People are outcome-based and value immediate and
    certain results
  • They make decisions to achieve the desired
    results
  • As they try to do more with less, they drift away
    from expected behaviors

20
Traditional View of Error and Violation
Deviation from Expected Behavior
Error
Violation
The Grey Area Intentional Variation
21
Work as Imagined Vs. Work in Practice
Normally Successful!
22
The Key
  • Event Prevention Happens Through Learning

23
The Organization
  • Individual behavior is influenced by
    organizational processes and values.
  • Systems Drive Behavior.

24
Organizational Processes
  • Workplaces and organizations are easier to manage
    than the minds of individual workers. You cannot
    change the human condition, but you can change
    the conditions under which people work.
  • Dr. James Reason

25
Organizational Values
  • Operational upsets can be avoided by
    understanding the reasons mistakes occur and
    applying the lessons learned from past events.

26
Barriers to a Learning Organization
  • 20 years of experience 1 year of experience
    repeated 19 times
  • Looking outside the organization is easier then
    asking the difficult internal questions
  • We confuse our scientific quest for cause with
    our emotional need for an explanation

27
Human to Systems Interface
  • People will never perform better than what the
    organization will allow
  • If a system relies on people doing the right
    thing every time, it will fail
  • No working system remains in stasis

28
Safety Redefined
  • Safety is not the absence of accidents
  • Safety is the presence of defenses in your
    processes, procedures, and methods.

29
Immediate Steps
  • Successful organizations seem to do four things
    very well
  • Constantly predicting the next failure
  • Consistently reducing operational complexity
  • Responding with urgency to pre-cursor data
  • Respond to actual events with deliberation

30
Conference Homework
  • Be more - Be just a bit smarter, nicer, more
    involved, happier, and a better co-worker.
  • Be the person who makes people feel good about
    who they areno matter who they are or what they
    do.
  • Perceive More about the world around youand by
    doing that you will make the world a much better
    place in which we work.
  • Build Communities of Thought.
  • Fake It Until You Make It.
  • Start Right Now.

31
Questions?
Bigtodd_at_lanl.gov
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