Fatalities & Serious Injuries

Transcription

1 New Strategies for Dealing with Fatalities & Serious Injuries Presented by Ron Gantt

2 Safety Differently 1. Safety is a capacity to be successful in varying conditions. 2. People are a solution to enable/facilitate. 3. Safety is an ethical responsibility from the organization to those doing the risky work. 2

3 Tragedy in La Porte Photo source - Marie D. De Jesus/Houston Chronicle 3

4 What are we going to talk about? 1. Why are fatalities and serious injuries (FSIs) different? 2. What is drift? 3. What doesn t work? 4. What can we do to reduce the potential for FSIs in our organization? 4

5 The Myth of Common Cause Between 1992 and 2015 o Incident rate decreased by 64% o Fatality rate decreased by 35% Last 10 years o Incident rate decreased by 35% o Fatality rate decreased by 16% Fatalities Injuries Near Misses/ Unsafe Acts 5

6 The Myth of Common Cause The Logical Argument There won t be 29 minor injuries for every fatality when dealing with a fall from a communications tower. There weren t 329 minor or near-incidents involving surface-to-air missiles before the downing of Malaysian Airlines Flight 17 Correlation Causation o For every conference you attended, you had 2-3 meals and 24 hours 6

7 Major events different than minor events? But why? 7

8 Human perceptions FSIs are low-frequency/high-consequence events These events defy experiential learning (trial and error) The safer we feel, the risker we tend to behave Road engineers with their accident statistics frequently dismiss condescendingly the fears of people living alongside busy roads with good accident records, heedless of the likelihood that the good accident records reflect the careful behavior of people who believe their roads to be dangerous. - John Adams Risk (1995) 8

9 An example (CSB, 2008) 9

10 But why do they sacrifice safety? Safety Boundary Effort/Workload Boundary 10

11 More is different What s the difference between and water? 11

12 Shift in thinking If you do what you ve always done, you ll get what you ve always got. But this is only true if the context never changes! 12

13 Organizational Drift The slow migration of work practices away from some idealized standard of how work should be done. Related to: Risk acceptance ( Normalization of deviance ) Procedure violations ( Practical drift ) 13

14 Here s the thing It is a mistake for us to think that the problem is people who don t care enough about safety! Each decision made sense to the people at the time and was designed to achieve success and avoid failure. 14

15 Too many critics of the organizational and political sources of our troubles see diabolical plots where there is only drift, a taste for reckless adventure where there is only ignorance of risks, the machinations of a power elite where there is, in William James' phrase, only a "bloomin' buzzin' confusion. - Diane Vaughan (1998) 15

16 BP Texas City ü Managers had an average tenure at the plant of less than 2 years. ü The plant measured safety performance with incident statistics, which showed they were near world-class levels. ü Benchmarking studies of maintenance spend indicated they spent more on maintenance than other refineries in the US. 16

17 What do we know so far? 1. Serious injuries and fatalities have different causes than minor injuries and incidents. 2. The causes of FSIs are related to risk perceptions in a fluid, imperfect world. 3. Organizations drift toward failure in ways that make sense at the time and often do not seem overly dangerous to the people involved. 4. Drift is not a product of stupid people. It s a product of normal organizational life. 17

18 What doesn t work? Incident trending (quantitative analysis) o There s simply not enough to tell you anything useful. Focusing more on safety o The problem is that people often aren t doing what they think is unsafe. The broken windows theory approach to safety o There s little or no relationship between holding hand rails and blowing up factories. Compliance approaches o More rules don t always make things better. 18

19 Ok, so what can we do? Don t take past success as a guarantee of future success Change the definition of safety in your organization. ü Stop or discourage initiatives based on the idea that safety is the absence of accidents. ü Safety is the capacity to be successful in varying conditions (resilience). Focus on assumptions that underlie normal work processes. ü You are safe based on what assumptions? ü Is that good enough? ü How would you know if those assumptions are no longer valid? 19

20 Ok, so what can we do? Focus on the conditions of work FSIs happen where work becomes difficult. ü Search for areas or times where there is a goal-means imbalance. ü Make work easier (build capacity, dampen variability, expand good practices). Focus on decision-making processes and information flows. ü Don t focus on outcomes. ü How does the right information get the right people at the right time? ü How would you/they be able to identify signals of impending danger (weak signals) from local improvements? 20

21 Ok, so what can we do? Make learning a value in your organization Create a continual learning (not just continual improvement). ü Accidents shouldn t be the only time you are learning. ü Beware the fallacy of centrality no news is not good news. Make space for learning. ü Provide time, resources, and people so that learning and reflection can occur. ü Encourage diverse viewpoints and build psychological safety. 21

22 Summary 1. FSIs are different than other types of incidents dealing with one doesn t necessarily lead to reductions in the other. 2. Getting people to care more about safety or be more compliant compliance doesn t really help with FSIs. 3. Change the definition of safety and create an environment where continual learning is possible. 22

23 The Safety Differently Track Tuesday, 2/21 Wednesday, 2/22 11a-12p Safety Differently An Introduction (A07) 1:30p-5p Beyond Root Cause Seeing Investigations Differently (A12) 10a-11:30a New Strategies for Dealing with Serious Injuries and Fatalities (B06) 1:30p-2:30p Safety Leadership From Constraints to Facilitation (B18) 2:45p-3:45p A Day in the Life Of Improving Work to Improve Safety (B23) 4p-5p Safety Differently What s Next? (B33)

24 Thank You Ron Gantt 24