CHRONIC UNEASE. September Albian Road Transport Forum. Dwaine Stovka Road Transport Specialist

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1 CHRONIC UNEASE Albian Road Transport Forum September 2013 Dwaine Stovka Road Transport Specialist 1

2 Understanding Chronic Unease Chronic Unease is about preventing complacency. It isn t a program but it is an important step changing our mindset from: We haven t had an incident, we are doing so well. To: We haven t had an incident - what are we overlooking and what else do we need to do? Chronic Unease is a pre-occupation with failure 2

3 Understanding Chronic Unease Background & Context The BP Deepwater Horizon incident in April 2010 was the largest ever deepwater blowout. The loss of life was tragic and the environmental damage was significant. This led to unprecedented loss in shareholder value, increasing regulation across the industry, and heightened public scrutiny of offshore drilling safety. 3

4 Understanding Chronic Unease Background & Context There are many incidents and they all share the same theme. There were warning signs and the warning signs were not acted on sufficiently to prevent the incident. Chronic Unease is about understanding the types of signs and how we process them as individuals. Images of global industrial incidents we don t own these 4

5 Elements of Chronic Unease Chronic Unease is about recognizing weak signals, taking action when they are observed and always watching for other signals. The intent of the following information is to give you the opportunity to deepen your understanding of Chronic Unease and the key aspects: Weak signals Cognitive bias Chronic Unease Thinking fast and slow 5

6 Understanding Chronic Unease Developing Reliability We learned that: As humans we tend to pay attention to loud signals. Sensitivity to weak signals is one of the building blocks of developing a chronic unease mindset That being alert to weak signals is a characteristic of high reliability. Oman 6 Fatalities

7 Discussion Weak Signals Weak signals are our CUE to take action. They are subtle signs which may indicate that some of the barriers intended to prevent an incident are failing or missing. Weak signals can likely be observed in the day to day operations of everyone involved in road transport We all need to be able to identify weak signals and respond strongly. 7

8 Discussion Cognitive Biases Cognitive biases are a natural tendency where our thinking is influenced by existing mental models, emotion or a lack of rationality. These biases can affect our perception and interpretation of information, including our: senses judgment and decision making 8

9 Discussion Cognitive Biases Cognitive bias can then lead to: Poor risk assessments Poor operational decisions Discussion Points: How do we ensure we make the right challenges at the right time to ensure that: Risk assessments are not degraded by cognitive biases? 9

10 Discussion Thinking Fast and Slow Nobel Prize winning psychologist Daniel Kahneman 1 uses a model where human thinking is divided into fast/instinctive and slow/ rational processes. Most often we are fast thinking, and it works well - most of the time. We have to recognise that when we are thinking like this we are subject to cognitive bias and jump to conclusions then look for the facts. When making HSSE Critical decisions, perhaps we need to engage our slow thinking rational brain more. 10

11 Discussion Thinking Fast and Slow Problem 1 10 X 10=?? Problem 2 A bat and ball together cost $110 The bat cost $100 more than the ball What does the bat cost? 11

12 Discussion Thinking Fast and Slow System 1- Fast Intuitive Effortless Emotional Irrational subject to bias Jumps to conclusion Suppresses ambiguity and doubt Automatic always on What you see is all there is System 2- Slow Deliberate Effortful Rational Evidence based Controls and monitors System 1 See ambiguity, experiences doubt Off unless switched on 12

13 Discussion Weak Signals The amount of near miss reporting we see is not proportionate to the number of incidents that are occurring... Heinrick s Law is a generalization of the progression of incidents in severity and is often demonstrated on a pyramid. While there is debate over the validity of the theory it is universally agreed that there are far more near miss incidents than there are actual incidents Near Miss incidents, in some cases, are the weak signals we should be picking up on as 13

14 Heinrich s Law Heinrich s theory indicates that near misses occur at a rate of ~10 near misses for every incident that occurs There are 67 incidents listed on the Road Transport incident tracker in the past 24 months. Following the logic of the theory there should be ~670 near miss reports. How many do you think there are? 14

15 Albian Logistics Contractor Incident Statistics Backing Incidents 3 Collision with 3 rd Party 10 Fixed Object Collisions 5 LOPC - 5 Near Miss 35 LSR Violation 3 Significant Windshield Rock Strikes 11 Wildlife Strikes 2 Other 28 Out of all incidents listed above none create more chronic unease than the near miss incidents reported and the uncertainty associated with the events that are not being reported Near miss incidents offer the same opportunity to learn as an actual incident without the consequences of an incident Challenge to everyone is to go back to your employees discuss the importance of near miss reporting and follow up if near miss reporting does not improve. 15

16 Breakout Session 6 min Part 1 At your tables take 3 minutes to share your thoughts on the best approach to get employees to report near miss incidents and agree on the approach that you believe will create the best results Part 2 Take 3 minutes to share your thoughts on sources of your chronic unease We will take a few minutes at the end to compare notes 16

17 What are my sources of unease? Accident statistics for local roads indicate high risk Near miss incidents at high risk/high traffic intersections along highway 63 Are the controls in the transportation Bowtie in place and are they effective enough to prevent incidents in such a high risk environment? 17

18 Highway 63 & 881 Statitistics 3339 Accidents and 93 fatalities from Accident Type: 5.5% Opposite Direction 16.6% Same Direction 34.1% Run Off Road 38.2% Animal 5.6% Other Source; Coalition for Safer 63 &

19 Review The Next Steps Embedding the mindset How we think not a program! Use LFI to provide learning opportunities Support for Businesses Website Share good practices and celebrate successes 20

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