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.
• Todd Conklin, Ph.D.
• Safety Improvements Initiative Office
• Los Alamos National Laboratory

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The Law of Unintended Consequences

• Never take a sleeping pill and a laxative at the
  same time

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Remember

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

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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.

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In my observation

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

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When Good Pets Go Bad
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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

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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.

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Murphys Law Revisited

• Anything that can go wrong.
• Probably wont.

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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.

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The Individual

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

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Origins of Human Error
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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.
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Limitations of Human Nature

• Errors arise directly from the way the mind
  handles information, not through stupidity or
  carelessness.
• Dr. Edward de Bono

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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.

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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.

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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.

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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.

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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

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Traditional View of Error and Violation
Deviation from Expected Behavior
Error
Violation
The Grey Area Intentional Variation
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Work as Imagined Vs. Work in Practice
Normally Successful!
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The Key

• Event Prevention Happens Through Learning

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The Organization

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

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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

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Organizational Values

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

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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

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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

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Safety Redefined

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

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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

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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.

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Questions?
Bigtodd_at_lanl.gov