SYSTEMS AND CHOICES: IT S ALL WE HAVE DAVID MARX

Transcription

1 SYSTEMS AND CHOICES: IT S ALL WE HAVE DAVID MARX JUNE 21, 2016

2 WHAT S IN A NAME? Accident Incident Mishap Misadventure Near miss Do they refer to an outcome? Do they refer to human action?

3 WHAT S IN A NAME? Pilot Error Maintenance Error Medication Error Driver Error Employee Mistake Do they refer to an outcome? Do they refer to human action?

4 OUR COLLECTIVE CULTURE? How bad was the outcome? Who did it?

5 THE SEARCH FOR BETTER ANSWERS Human Factors: It s not the human, it s the system we designed around the human.

6 NOT EVERYONE GOT THE MESSAGE Vision Zero: Zero Preventable Harm. Zero Preventable Injuries.

7 SUBWAY SAFETY NEW YORK CITY

8 THE PROBLEM, AND THE SOLUTION

9 WHAT ABOUT BETTER SYSTEM DESIGN?

10 YET, IT S NOT ONLY ABOUT SYSTEM DESIGN

11 FOCUSING ON THE RIGHT THINGS Monitor it all But actively manage: System Design Safety Culture Employee Injured Near Misses Design of the System Behavioral Choices within the System

12 SAFETY How do we prevent backing over a child?

13 SOLUTIONS? TECHNOLOGICAL SYSTEMS Backup camera Backup sensor with automatic breaking Backup horn PROCEDURAL SYSTEMS Walk around back of car before getting in Use a spotter Yet, the most simple of steps, the walk around, most drivers do not do Is that our culture?

14 UNDERSTANDING WHO WE ARE

15 UNDERSTANDING WHO WE ARE We are inherently self-serving, occasionally altruistic, happinessseeking, inescapably fallible, pack animals blessed (or cursed) with free will and a mis-tuned ability to see and avoid hazards in the world around us

16 CHOICES = CULTURE I know, I know. I cannot reach the top. Hey, do we have a third ladder? Hurry, Bob, the game is going to start in 10 minutes

17 A SIMPLE MENTAL MODEL Sight Sound Smell Taste Touch Pursuit of the Mission The Risk Monitor (background process, harm focused) Perception Interpretation and Decision-Making Action

18 THE LIMITS OF NATURAL CONSEQUENCES Choice Desired and Undesired Outcomes The less likely the undesired outcome, the more distant the undesired outcome, the harder it is to see the link between a risky choice and the undesired outcome it may cause.

19 HOW WE MAKE CHOICES Life, Liberty, and the Pursuit of Happiness Pursue our individual mission, while trying to respect our shared values We are NOT inherently rule followers (we take them under advisement) We ARE hazard and threat avoiders Natural and man-made hazards Values-based threats Engineered threats

20 RESPONDING TO HAZARDS AND THREATS Man-Made Hazard Values-Based Threat Engineered Threat

21 CULTURE The degree to which human beings will, through their choices, be protective of a shared value. This often appears as the extra effort it takes to act in protection of a value, in the face of a belief that potential harm is uncertain, delayed, or will simply happen to someone else.

22 AND WHAT OF THE LINK BETWEEN CULTURE AND SANCTION?

23 THE JUST CULTURE A system of substantive justice (disciplinary and enforcement action) that reflects what we now know of socio-technical system design, free will, and our inescapable human fallibility.

24 THROWING OUT THE CURRENT APPROACH How bad was the outcome? Who did it?

25 BEHAVIOR IN THE HUMAN BEHAVIOR JUST CULTURE Human Error - At-Risk Behavior - Reckless Behavior - inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake. behavioral choice that increases risk where risk is not recognized or is mistakenly believed to be justified. behavioral choice to consciously disregard a substantial and unjustifiable risk.

26 A BETTER USE OF SANCTION? Human Error At-Risk Behavior Reckless Behavior Product of Our Current System Design and Behavioral Choices Manage through changes in: Choices Processes Procedures Training Design Environment A Choice: Risk Believed Insignificant or Justified Manage through: Removing incentives for at-risk behaviors Creating incentives for healthy behaviors Increasing situational awareness Conscious Disregard of Substantial and Unjustifiable Risk Manage through: Remedial action Punitive action Console Coach Sanction

27 THE THREE BEHAVIORS At-risk behavior is generally the biggest threat to system safety The amount of atrisk behavior is the key measure of safety culture

28 IN THE END

29 UNDERSTAND WHAT WE CAN CONTROL Systems + Choices = Outcomes Reliable Systems + Good Choices = Good Outcomes

30 ACKNOWLEDGE THAT PERFECTION IS NOT POSSIBLE We build a system comprised of inescapably fallible human beings. As a consequence, perfection itself is not possible. (there is no such thing as a never event) Risk A Risk Profile for a Single Class of Outcome (e.g., employee falls) That said, we set an expectation, we design the system, we manage within the system, we continuously audit/assess/learn As Low As Reasonably Practicable (ALARP) 10-9 Time

31 WE CAN BUILD A STRONG SAFETY CULTURE Articulate safety as an organizational value Design your systems to support safe choices Audit (look for safety supportive choices) Be a role model (resolve dilemmas in a manner that demonstrates your commitment to safety) Mentor (help others resolve dilemmas in the right way) Coach (call it out when you see choices that are unsafe) Hold everyone accountable for the right choices (unresponsive to coaching, or reckless -- go home)

32 THANK YOU