Documentos de Académico
Documentos de Profesional
Documentos de Cultura
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Why This Class, Now? We are very efficient at conducting accident investigations, but. Why do events continue to happen? Why are our responses so ineffective? Why dont we seem to fix the right things?
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Rule Based
Goal Based
Improvement Based
People who make mistakes are blamed for their failure to comply with rules
Mistakes are seen as process variability with emphasis is on understanding what happened, rather than finding someone to blame
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Learning
Learning is about changing our belief systems Learning is about seeing the failure as a part of the system. Learning is about increasing the flow of safety-related information. Learning is about countermeasures that remove error-producing conditions so there will not be a next time Learning is about continuity, the event firmly integrated in what the system knows about itself.
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Additional concepts on performance variability, accident models, and procedures come from publications by Erik Hollnagel, University of Linkping, Sweden. His books include:
Barriers and Accident Prevention, 2004
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On 6/12/03, a Civil Air Patrol Cessna 182 based out of Los Alamos and flown by a Los Alamos Squadron pilot, stalled and crashed shortly after takeoff while towing a Schweizer 2-33 glider at the CAP Glider Encampment in Hobbs, NM.
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Consequence is not the whole story Sometimes complex accidents result in little or no consequence Likewise, relatively simple accidents, can result in a significant consequence All events should be investigated and the level of effort should be determined on-the-fly The causes should reflect the substance of the event, not the consequence
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Module One:
Errors and Performance Variability Meaning Right While Doing the Wrong Things How We Look at Accidents Cause and Effect Barrier Analysis Perils and Pitfalls Event/Decision Charting
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Improvement Based
Human error is a symptom of trouble deeper within the system Safety is not inherent in most systems, workers have to create safety by their actions Human error is connected to features of the tasks and operating environment Progress on safety comes from understanding and influencing these connections
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70%
Traditional View: Operational Upsets
System Induced Error
30%
90%
Human Error
10%
Equipment Failures
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Operated by Los Alamos National Security, LLC for NNSA
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Rule Based
Goal Based
Improvement Based
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Think of human error as a deviation from expected performance, which includes both unintended and intended actions
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Performance Modes
High
Kn Inaccurate ow led Mental Picture ge -B Pa a tte rns sed
If
Ru le
-T
Misinterpretation
he n
Ba se
Sk il
Inattention
Low Low
l-B ase Au d to
High
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Gray Area
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This notice of deviation or consequence could be almost immediate by the worker or it could be delayed In hindsight, errors seem obvious and compelling, but from the view of the people at the time, they were just doing their job
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Knowledge influenced
Actions taken by knowledgeable workers with intent to produce a better outcome
When successful, the actions are condoned and rewarded When they are unsuccessful or outcome is bad, the actions are quickly judged as violations
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Efficient
Thorough
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Sense
Act
? ? ?
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Looks OK to me Not really important No time (or resources) to do it now If I do it this way, I can save time/money Boss says it must be ready in time I know a better way to do it We must get this done
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Performance variability
Sense
Act
? ? ?
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Rule Based
Goal Based
Improvement Based
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A quick example
A questionnaire study of 286 aircraft maintenance engineers found that 34% did not follow the official procedure for a task they just completed. Of these: 45% said there was an easier way 43% said there was a quicker way
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Procedures are resources for action (among other resources) Applying procedures successfully is a substantive, skillful cognitive activity Safety often comes from people being skillful at judging when and how procedures apply
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Event
Initiating Action
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Time
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Caused by unsafe acts or conditions Prevented by finding and eliminating possible causes
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Caused by degradation of components (organizational, human, technical) Prevented by strengthening barriers and defenses
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Caused by unexpected combinations of normal actions rather than action failures. Solution is to understand the nature of variability (why, when, how) and how to limit it when it can be dangerous
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Module Two:
Errors and Performance Variability Meaning Right While Doing the Wrong Things How We Look at Accidents Cause and Effect Barrier Analysis Perils and Pitfalls Event/Decision Charting
UNCLASSIFIED
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In practice, causes are often expressed as Worker did not follow (or violated) the procedure Inadequate details in the procedures Inattention or complacency by the involved worker Inadequate training or retraining Inadequate supervision that allowed the error to occur Lack of management attention and oversight
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In practice, corrective actions include Disciplinary action, real or perceived, for the involved worker/supervision Retraining of the involved workers Additional training for all workers Changes in the procedure or more procedures Increase in supervisory/management oversight
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Our processes would be fine, were it not for the erratic behavior of some unreliable people (bad apples) AKA: cowboys and buttheads Safety will be achieved when the bad apples are either fixed or eliminated
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Discussion:
Although we believe strongly that we have competent and motivated workers, why do we revert so quickly to a conclusion of bad apples when there is an accident or security event
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Module Three:
Errors and Performance Variability Meaning Right While Doing the Wrong Things How We Look at Accidents Cause and Effect Barrier Analysis Perils and Pitfalls Event/Decision Charting
UNCLASSIFIED
Operated by Los Alamos National Security, LLC for NNSA
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Proximal
We tend to focus on those people who were closest to producing or potentially avoiding the accident Rather than recognize weakness in the system, the tendency is to see a localized problem where the people have acted in an irrational manner We tend to ignore the organizational influences on behavior that result from a multitude of conflicting constraints and pressures (be thorough, but also efficient)
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Retrospective
Investigations aim to explain an event in the past, but are conducted in the present As an investigator, you will probably know more about the event than the people involved Because you assessing peoples decisions and actions with hindsight, based on what you know now, you cannot be truly objective about their performance
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Solve the maze, then raise maze is to The quickest way to solve theyour hand start from the FINISH and work backwards
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We are not alone, a recent example from the National Transportation Safety Board
On August 27, 2006, Comair flight 5191, crashed during takeoff from Blue Grass Airport, Lexington, Kentucky. The flight crew was instructed to take off from runway 22, but instead lined up the airplane on runway 26 and began the takeoff roll. The airplane ran off the end of the short runway and impacted the airport perimeter fence, trees, and terrain. The captain, flight attendant, and 47 passengers were killed.
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The NTSB Board determined the probable cause(s) of this accident as follows:
The flight crews failure to use available cues and aids to identify the airplane's location on the airport surface during taxi, The flight crews failure to cross-check and verify that the airplane was on the correct runway before takeoff, and The FAAs failure to require that all runway crossings be authorized only by specific air traffic control clearances.
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Because we are working backwards with the benefit of a known outcome, we can easily see how they could have avoided the accident The trouble is, this is not how the involved people experienced the accident, and does not explain how failure succeeded
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Micro-matching procedures
Investigations invest considerable effort in organizational archeology to reconstruct the regulatory and procedural framework in which the operation took place In hindsight, discrepancies between procedures and practice are easily unearthed But, discrepancies between procedure and practice are common and are not especially unique to the accident circumstances The result is worker did not follow procedures as a cause
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An HPI approach Although we like to appear knowledgeable, interview the workers before reviewing the documents This will help you to understand the context in which they experienced the event Let the worker explain what happened in his own words
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The problem is they are usually only relevant with knowledge of the outcome (hindsight)
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Cherry-picking
Information can be taken out of context by grouping and labeling fragments that, in hindsight, appear to represent a common condition Often the investigator notes a particular fact, develops a theory (opinion), and searches for other evidence to support the theory
The team leader was located at another site The team leader only visited the workers site about once a month
The fragments of information are used to construct a story that explains the cause of the accident
Infrequent management presence led to an inconsistent implementation of safe work practices, methods, and behaviors.
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Module Four:
Errors and Performance Variability Meaning Right While Doing the Wrong Things How We Look at Accidents Cause and Effect Barrier Analysis Perils and Pitfalls Event/Decision Charting
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For our purposes, it is why the accident happened and is expressed in the context of cause and effect.
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Cause A
Effect B
Observable
Observable
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Cause?
Effect B
Observable
Observable
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1. The cause must precede the effect (in time) 2. The cause and effect must be contiguous (close) in
time and space
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For example
The first cause of this event was a lack of direct supervision of the worker which resulted in a worker being able to perform work in a manner that was unsafe Is there a cause effect relationship?
The lack of direct supervision preceded the accident The lack of supervision had existed for years
Lack of direct supervision does not always cause work to be performed in an unsafe manner
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WYLFIWYF*
The cause you find usually depends on: where you look, what you look for, who you talk to, what you have seen before, and likely, who you work for It often says more about the investigator than the accident! * What You Look For Is What You Find
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According to Airline
Controllers clearances were not in accordance with standards Inadequate language skills and inattention by the Controller Inadequate automation database supplied to computers Lack of radar coverage over area Workload increase because of Controllers sudden instruction to use novel arrival route and different runway
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Module Five:
Errors and Performance Variability Meaning Right While Doing the Wrong Things How We Look at Accidents Cause and Effect Barrier Analysis Perils and Pitfalls Event/Decision Charting
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Why barriers?
Re + Md E
reducing errors AND managing defenses lead to zero events
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Physical Administrative
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Physical physically prevents an action from being carried out or an event from happening Containing or protecting - walls, fences, railings, containers, tanks Restraining or preventing movement - safety belts, harnesses, cages Separating or protecting Crumple zones, scrubbers, filters
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Functional impedes actions through the use of pre-conditions Prevent movement/action (hard) locks, interlocks, equipment alignment Prevent movement/action (soft) passwords, entry codes, palm readers Impede actions delays, distance (too far for single person to reach) Dissipate energy/extinguish air bags, sprinklers
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Symbolic requires an act of interpretation in order to achieve their purpose Countering/preventing actions demarcations, signs, labels, warnings Regulating actions instructions, procedures, dialogues (pre-job brief) System status indications signals, warnings, alarms Permission/authorization permits, work orders
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Incorporeal requires interpretation of knowledge in order to achieve their purpose Process rules, restrictions, guidelines, laws Comply/conform self-restraint, ethical norms, morals, social or group pressure
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Evaluation of barrier system quality Effectiveness how well it meets its intended purpose Availability assurance the barrier will function when needed Evaluation how easy to determine whether barrier will work as intended Interpretation extent to which the barrier depends on interpretation by humans to achieve its purpose
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Symbolic Incorporeal Medium High Difficult High Low Uncertain Difficult High
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Module Six:
Errors and Performance Variability Meaning Right While Doing the Wrong Things How We Look at Accidents Cause and Effect Barrier Analysis Perils and Pitfalls Event/Decision Charting
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Sydney Dekkers five steps for reconstructing human error contributions to accidents
1. Lay out the sequence of events and decisions in a
rough timeline
2. Divide the sequence into episodes, if necessary 3. Find out how the world looked or changed during each
episode
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Event/Decision Charting
This is a variation of the traditional Events and Causal Factors (EC&F) Charting that we developed to incorporate human performance
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Sequence of events
The sequence of events forms the starting point for reconstructing the accident The events include observations, actions, and changes in the process or system. The decisions (before an action) will start to establish the mindset of the worker The goal is to set the framework for how the workers perception unfolded in parallel with the situation evolving around them
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Sequence of Events and Decisions Add add in the DECISIONS, ThenEVENTS and ACTIONS before the actions
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People have knowledge, but the application of knowledge is not straight forward
Was it accurate, complete and available
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Explanation
Provide an explanation of what the workers did and why they did it What was happening with the process What the workers were trying to accomplish and why What they knew at the time Where their attention was focused and why Why what they did made sense to them at the time
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Workers use large conveyor instead of small conveyor to unload front compartment of truck, causing damage
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A: Why did they was in large conveyor instead of the Q: The small oneuse the the remote storage area and they one? smalldidnt want to take the time to get it
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A: Why moved there before the the storage Q: They was theitsmall conveyor in truck arrivedarea?
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A: Why didnt think they would need Q: They did they move it to storage? it
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A: Why had been think they would need it? Q: They didnt theytold the front compartment was empty
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A: But, get did they move it before the truck Q: Theywhy to go home when the last truck is unloaded arrived? and wanted to be ready to leave ASAP
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Finally, when they found out there was cargo in the front, they thought they could use the large conveyor safely
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Look at the incentive structure If you say they can go home after the last truck, expect them to start packing everything but the bare essentials away before the last truck arrives When confronted with a surprise (unanticipated load), also expect them to improvise with the tools at hand Possible solutions include working to a set time, provisions for overtime pay, and improved information about loads
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How do you know you got it right? You cant The story we write about past performance is always tentative
New information can prove you wrong New interpretations may be better than yours
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