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Error Traps: Finding your next failure Paul Gantt, CSP, CET Ron Gantt, CSP, CET
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ERROR TRAPS: FINDING YOUR NEXT FAILURE Paul Gantt, CSP, CET Ron Gantt, CSP, CET.

Dec 17, 2015

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Page 1: ERROR TRAPS: FINDING YOUR NEXT FAILURE Paul Gantt, CSP, CET Ron Gantt, CSP, CET.

Error Traps: Finding your next failurePaul Gantt, CSP, CET

Ron Gantt, CSP, CET

Page 2: ERROR TRAPS: FINDING YOUR NEXT FAILURE Paul Gantt, CSP, CET Ron Gantt, CSP, CET.

Introduction

Paul Gantt, CSP, CET• President and Founder

at Safety Compliance Management

• Retired Fire Chief Officer/Fire Marshal

• Master of Engineering in Advanced Safety Engineering and Management (in progress)

Ron Gantt, CSP, CET• Vice President, Operations

at Safety Compliance Management

• Degrees in OSH and Psychology

• Master of Engineering in Advanced Safety Engineering and Management (in progress)

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Page 3: ERROR TRAPS: FINDING YOUR NEXT FAILURE Paul Gantt, CSP, CET Ron Gantt, CSP, CET.

Session Objectives• To discuss human error and its effect on occupational

safety.

• To identify the role of error traps in human error.

• To identify how an organization can identify and eliminate error traps to prevent incidents.

• To review case studies involving human error.

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Page 4: ERROR TRAPS: FINDING YOUR NEXT FAILURE Paul Gantt, CSP, CET Ron Gantt, CSP, CET.

Case Study #1 – Another Ladder AccidentEmployee replacing a street sign falls off of a ladder (approximately 12’):

• Immediate Result – Broken ribs and vertebrae.

• Direct Cause – Employee likely leaned out while on ladder, causing the ladder center of gravity to shift.

• OSHA investigated, no citation issued (“Employee Error”).

• Corrective Action – Name, Blame, Shame, and Retrain.

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Page 5: ERROR TRAPS: FINDING YOUR NEXT FAILURE Paul Gantt, CSP, CET Ron Gantt, CSP, CET.

Heinrich Warned Us About This!

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Page 6: ERROR TRAPS: FINDING YOUR NEXT FAILURE Paul Gantt, CSP, CET Ron Gantt, CSP, CET.

Perhaps its more complicated?

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Source: DOE (2007)

Page 7: ERROR TRAPS: FINDING YOUR NEXT FAILURE Paul Gantt, CSP, CET Ron Gantt, CSP, CET.

Case Study #1 - Lets Look Deeper• Company had no effective job hazard analysis or hazard

correction programs.• Safety programs/culture was reactive, rather than

proactive (safety was an afterthought).• Employee was called in to work at the last minute.

• On his day off• On the day he was leaving for vacation to Las Vegas• On his 25th wedding anniversary

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Page 8: ERROR TRAPS: FINDING YOUR NEXT FAILURE Paul Gantt, CSP, CET Ron Gantt, CSP, CET.

Knowing what we know now…

Could we have predicted that an incident was more likely to happen?

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Page 9: ERROR TRAPS: FINDING YOUR NEXT FAILURE Paul Gantt, CSP, CET Ron Gantt, CSP, CET.

Thinking about human error

• People make mistakes!• Blaming someone for being human (i.e. making an

honest mistake) isn’t helpful.• Especially if the error is predictable and preventable

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“Human error is a symptom of trouble deeper in the system.”

-Sidney Dekker

Page 10: ERROR TRAPS: FINDING YOUR NEXT FAILURE Paul Gantt, CSP, CET Ron Gantt, CSP, CET.

Case Study #2 – The Downside of Consistency

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Page 11: ERROR TRAPS: FINDING YOUR NEXT FAILURE Paul Gantt, CSP, CET Ron Gantt, CSP, CET.

What is an Error Trap?• Violates operator expectations.• Requires performance beyond what an employee can

deliver.• Induces fatigue.• Provides inadequate facilities or information for the

operator.• Is unnecessarily difficult or unpleasant.• Is unnecessarily dangerous.

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Page 12: ERROR TRAPS: FINDING YOUR NEXT FAILURE Paul Gantt, CSP, CET Ron Gantt, CSP, CET.

Error Traps have many sources

Task Demands• Time Pressure• Unclear goals

Work Environment• Distractions• Confusing displays or

controls

Individual Capabilities• Task unfamiliarity • Illness or fatigue

Human Nature• Complacency• Mental shortcuts/biases

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Page 13: ERROR TRAPS: FINDING YOUR NEXT FAILURE Paul Gantt, CSP, CET Ron Gantt, CSP, CET.

Case Study #3 – Recent Events

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Page 14: ERROR TRAPS: FINDING YOUR NEXT FAILURE Paul Gantt, CSP, CET Ron Gantt, CSP, CET.

Case Study #3 – Open and Shut Case

• The train engineer admitted he was nodding off. His lawyer said it was a case of “highway hypnosis.”

• “Most people are leaning towards human error” – A union official.

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Page 15: ERROR TRAPS: FINDING YOUR NEXT FAILURE Paul Gantt, CSP, CET Ron Gantt, CSP, CET.

Case Study #3 – Some Questions

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• Is it likely that a human being will get bored and distracted in an environment where they are required to passively monitor a system?• If yes, does the rail industry not know about it?

• What systems are in place to get an engineer’s attention when a safety critical task is coming up?

• Is there technology available that automatically slows trains if not done so manually when there is a significant change in speeds at a safety critical point (e.g. “autopilot”)?

Page 16: ERROR TRAPS: FINDING YOUR NEXT FAILURE Paul Gantt, CSP, CET Ron Gantt, CSP, CET.

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Page 17: ERROR TRAPS: FINDING YOUR NEXT FAILURE Paul Gantt, CSP, CET Ron Gantt, CSP, CET.

The people The system

It’s the people in the system

IT’S B

OTH

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Page 18: ERROR TRAPS: FINDING YOUR NEXT FAILURE Paul Gantt, CSP, CET Ron Gantt, CSP, CET.

Dealing with error traps

We have to understand that people will be people!• Make it easy for employees to do the right thing.• Make it hard for employees to do the wrong thing.• Make it so that when they do the wrong thing it doesn’t lead to

catastrophe.

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Make the system conform to the people, not the other way around!

Page 19: ERROR TRAPS: FINDING YOUR NEXT FAILURE Paul Gantt, CSP, CET Ron Gantt, CSP, CET.

Remember the Hierarchy

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Page 20: ERROR TRAPS: FINDING YOUR NEXT FAILURE Paul Gantt, CSP, CET Ron Gantt, CSP, CET.

We need a balance

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Consider the automobile industry’s approach to your safety.

Page 21: ERROR TRAPS: FINDING YOUR NEXT FAILURE Paul Gantt, CSP, CET Ron Gantt, CSP, CET.

Case Study #4 – Going Up or Down?

• Turnaround (maintenance shutdown) activities at a local chemical plant.

• “Critical path” was at one process vessel where employees would climb 20’-30’ ladders routinely to access scaffold.

• Turnaround scheduled in winter months, rain was expected.

• Employees may be wearing PPE to protect against chemical hazards at times, reducing dexterity.

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Page 22: ERROR TRAPS: FINDING YOUR NEXT FAILURE Paul Gantt, CSP, CET Ron Gantt, CSP, CET.

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We built an elevator

Page 23: ERROR TRAPS: FINDING YOUR NEXT FAILURE Paul Gantt, CSP, CET Ron Gantt, CSP, CET.

Take Aways• Human’s make mistakes. • To prevent incidents involving human error in your

organization:• Stop blaming the workers• Start looking for the error traps

• Create an environment where:• It’s easy to do the right thing.• It’s hard to do the wrong thing.• Doing the wrong thing doesn’t lead to catastrophe.

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Page 24: ERROR TRAPS: FINDING YOUR NEXT FAILURE Paul Gantt, CSP, CET Ron Gantt, CSP, CET.

Finding Error Traps

• As part of facility audits

• In the management systems

• As part of a JHA process

• In the design process (PtD)

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Page 25: ERROR TRAPS: FINDING YOUR NEXT FAILURE Paul Gantt, CSP, CET Ron Gantt, CSP, CET.

Questions?Paul Gantt, CSP, CET

Ron Gantt, CSP, CET

Slides available at our website: http://www.scm-safety.com