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THELACKOFHUMANRELIABILTYDATAISA
BARRIERTOTHEATTAINMENTOFNSABBS
RISKREDUCTIONOBJECTIVES
GavinHuntleyFenner,PhD
NASGainofFunctionSymposium
March1011,2016

TOPICS

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WhatisHumanFactors?
TheroleofHumanFactorsdata
inbiosafetyandbiosecurity
Theopportunity:Wehavethe
meanstoknow
Futureoptions

WHATISHUMANFACTORS?

Humanerrorisestimatedasfactorin:
>80%ofmotorvehicleaccidents
80%ofmedicalerrors
60%to80%ofaviationaccidents

Sources:Kohn,LindaT.,JanetM.Corrigan,andMollaS.Donaldson,eds.ToErrIsHuman::BuildingaSaferHealthSystem.Vol.627.NationalAcademiesPress,2000.
Foushee,H.Clayton."Dyadsandtriadsat35,000feet:Factorsaffectinggroupprocessandaircrewperformance."AmericanPsychologist 39.8(1984):885.Cooper,
JeffreyB.,etal."Preventableanesthesiamishaps:astudyofhumanfactors."Anesthesiology 49.6(1978):399406.AsreportedintheFHWAHighwaySafety
ImprovementProgramManual,EC/IRUStudy;
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Thestudyofhumanreliability,drawingonan
understandingofhumancapabilitiesand
limitationsinvariousenvironments.

Thelackofhuman
factorsresearchin
thelifesciencesis
somethingthatneeds
tobeaddressed.
Casagrande

TheU.S.governmentshould
continueeffortswhichwill
fosteracultureofresponsibility
thatwillsupportnotonlythesafe
conductofGOFstudiesofconcern
butofallresearchinvolving
pathogens

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Sources:

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FOCUSONNSABBRECOMMENDATON4AND
TYPESOFDATATOACHIEVETHEOBJECTIVE

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HUMANERRORHASINCREASED
PROPORTIONALLYASACONTRIBUTORTO
ACCIDENTS

Sources:AsreportedintheFHWAHighwaySafetyImprovementProgramManual,EC/IRUStudy;Hollnagel,E.(1993).Thereliabilityofcognition:
Foundationsofhumanreliabilityanalysis,London,UK:AcademicPress

 Increasedfatiguedue
tohoursworked
Cellphonesandother
distractions
PoorWorkingPosture
Load Workingwith
sharp,hot,coldor
toxic/hazardous
objects
Personnelprotective
equipmentmaymake
workmoretaxing.

Reduced
applicationofskill
Impairedcognitive
functioning

Sources:MaximizingUserSafetyThroughHumanFactorsDesign,LabconcowhitepaperbyBrianGarrett(2013)

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PHYSICALANDCOGNITIVESTRESSES
UNDERMINEHUMANRELIABILITY

Despiteadvancesintechnology,
instrumentsandPPE:
.humanerrorremainsoneofthe
mostimportantfactorsattheoriginof
accidents

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Sources:

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THEWHOCALLSOUTHUMANERRORASA
PRIMARYLABBIOSECURITYCONCERN

Thestateofknowledgeofthe
ratesandconsequencesofhuman
errorsinlifesciencelaboratoriesis
toopoortodeveloprobust
predictionsoftheabsolute
frequencywithwhichlaboratory
accidentswillleadtolaboratory
acquiredinfections...

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Sources:

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THEREISANIMPERATIVETOCOLLECTBETTER
DATA(Gryphon,2016)

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NOSOLACEFROMFEWADVERSEEVENTS,AS
FORENSICSSHOWSHIDDENORLATENTDATA

manyotherincidentsand
accidentshaveoccurred,
mainlyasaresultofhuman
errororequipmentfailure.
Fortunately,most
incidents/accidentsdonot
haveseriousconsequences

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2009GAOINVESTIGATIONHIGHLIGHTED
UNDERAPPRECIATEDHUMANERROR

No.
HumanFactorsprovidestools
fordesigning,implementing
andmaintainingsystemsin
whicherrorshavelimited
impactwhentheydooccur.

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DOESTHEINEVITABILITYOFHUMANERROR
ARGUEAGAINSTCONTINUINGGOFRC?

TrainingTarget

Risk Reduction

Seasonal
Influenza

7x

Coronavirus

10x

Hand
contamination

50x

Worker Error

100x

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THEBENEFITSOFINCORPORATINGHUMAN
FACTORSPRINCIPALSAREPOTENTIALLY
SIGNIFICANT

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Sources:RiskandBenefitAnalysisofGainofFunctionResearchDraftFinalReportDecember2016

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SIMPLEAPPROACHESCANYIELDSIGNIFICANT
REDUCTIONINERRORS

40%
reduction
inerrors
Source:Haynes,AlexB.,etal."Asurgicalsafetychecklisttoreducemorbidityandmortalityinaglobalpopulation."NewEnglandJournalofMedicine
360.5(2009):491499.

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NASARECENTLYFACEDHUMANERRORDATA
SHORTAGE&INTENSIFIEDDATACOLLECTION

Sources:Chandler,F.,Heard,I.A.,Presley,M.,Burg,A.,
Mideen,E.,&Mongon,P.(2010).NASAhumanerroranalysis.
NationalAeronauticsandSpaceAdministration,FinalReport.

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BHF1

SURVEYOFLABORATORYAQUIRED
INFECTIONSINEUROPE(68INSTITUTIONS)

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Reportsthat95%involvedhumanerror

15

Slide 15
BHF1

What is the stat of 95% based on? And how does the arrow tie to human error?
Beth HF, 3/10/2016

RecommendsMultifaceted
interventions
Modelingofthebehaviorby
supervisorsandcoworkers,
Implementationofwritten
handwashingpolicies
Reductionofexitfrequency

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THEFIELDISPOSITIONEDTOPROVIDERELEVANT
DATABUTMOREBSL2/3WORKISNEEDED

[cuttingcorners]were
mainlyfoundtobedueto
situationalandorganizational
factors.Forexample,time
pressure,workload,staffing
levels,training,supervision,
andavailabilityofresources

HumanfactorsthatleadtononcompliancewithstandardoperatingproceduresSimonBates&JustinHolroyd
HealthandSafetyLaboratoryHarpurHillBuxtonDerbyshireSK179JNhttp://www.hse.gov.uk/research/rrpdf/rr919.pdf

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CONTEXTDATAAREALSOIMPORTANT(FOCUS
GROUPSIN6UKCL3LABS)

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STAFFINUSIMPACTEDBYGROWTHOF
ENVIRONMENTALHEALTHANDSAFETYREGS

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Sources:GreenBlueascitedinSimpson,S.A.(2016).Astudyofsafetyclimateandemployees'trustoftheirorganizational leadershipinuniversityresearchlaboratories.

RECOMMENDRIGOROUSDATAAND
SOPHISTICATEDANALYTICSTOREDUCERISK

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Suggestcreatingnationalreportingstandardsthatgo
beyondthemostsignificantadverseevents
Collectingnearmissesisreallyimportant(thebulkof
theiceberg)
Sometypesofeventsarerare(wethink)socollecting
acrossmultiplebodieswouldbeprudent
Optimalsolutionistostandardizedatainputs;this
wouldincreasethepoolofinformationforanalysisand
theapplicabilityofanydatadrivenapproachesto
reducingrisk

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Sources:GoogleSelfDrivingcarProjectMonthlyReport,November2016

BHF2

LOOKINGFORWARDTOFURTHERREDUCTION
OFRISKTHROUGHSOPHISTICATEDANALYTICS

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Forexampleanalyticsdrivenmodelsofwhenandwhen
adverseeventsaremorelikelytooccurandunderwhat
circumstances
Inotherindustries,thesetypesofmodelshaveleadto
designstofurtherlowerrisk.Theycanalsoleadto
enhancedresearchproductivity.
Wehaveadditionalopportunitiestodirecttrainingand
otherinterventionswheretheyareneededmost

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Slide 20
BHF2

Do you want to add the police example here? I think this will drive home the point that reporting on the near misses is a predictor of
which labs have the highest risk levels.
Beth HF, 3/10/2016

 6Years
2Millionmiles
17Minor
accidents

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Sources:GoogleSelfDrivingcarProjectMonthlyReport,November2016

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RISKREDUCEDTHROUGHRIGOROUSDATA
ANDSOPHISTICATEDANALYTICS

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THEROLEOF HUMANFACTORS

ThankYou

5319UniversityDrive,#137,Irvine,California92612 | 949.682.9887 | gavin@huntleyfenneradvisors.com

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Enhancepreparedness
Preventsignificantaccidents
Mitigateconsequences
Improveproblemsolvingafteradverseevents
Identifydataneededtosupportrigorousanalysis
Supportdecisionsregardingallocationoflimitedresources
Sunshineimplicitrisksadoptedbyateam
Sunshinehiddenorunderappreciatedbenefitsofexisting
practice
Robustbiosafetyenvironmentcanhardenbiosecuritytarget

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ORGANIZATIONSBENEFITFROMHUMAN
FACTORFOCUSAPARTFROMRISKREDUCTION

E.g.,acceptablerisksareadoptedprojectby
projectorlabbylab

Wetendtounderestimate
cumulativerisk
Weareoptimisticabout
ourcapacitytocontrol
localrisk
Needtobeawareof
potentialtoaccruebenefits
(science)&externalizerisks
(publichealth)

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BEWAREOFOURLIMITEDCAPACITYTO
UNDERSTANDANDMANAGERISK