Human Error Investigations

Human Error InvestigationsIMPROVEMENT
T. Shane Bush Peggy S. Bush (208) 521-5180 2020 Stosich Lane Idaho Falls, ID 83402 [email protected]
Paul Bierley Left
A little fun fact.
How many of you (by a raise Hands), know where the term “Riding Shotgun” came from?
“Everybody is a genius, but if you judge a fish by it’s ability to climb a tree it will live its whole life
believing it is stupid.” - Albert Einstein
Failing Safely: An organization’s ability to experience failure free of injury, damage, or mission interruption.
Safety is not the absence of events (outcomes) but the presence resilience Stop seeing safety as an outcome and starting seeing safety as a capacity Humans are fallible and processes are not inherently safe Failures must be anticipated Safety Capacity (resilience) must be created Critical Steps must be understood and identified
We tend to focus on this gap
Capacity of Resilience focuses
Context !
No Hero’s Today!
While Humans can control (to some extent) their behaviors, they cannot control physics.
Error Precursors (short list) Task Demands Individual Capabilities
• Time pressure (in a hurry) • Unfamiliarity with task / First time • High workload (memory requirements) • Lack of knowledge (mental model) • Simultaneous, multiple tasks • New technique not used before • Repetitive actions / Monotony • Imprecise communication habits • Irrecoverable actions • Lack of proficiency / Inexperience • Interpretation requirements • Unsystematic problem-solving skills • Unclear goals, roles, or responsibilities • “Can do” attitude for crucial task • Lack of or unclear standards • Illness or Fatigue
Work Environment Human Nature • Distractions / Interruptions • Stress • Changes / Departure from routine • Habit patterns • Confusing procedure / Vague guidance • Assumptions • Confusing displays / controls • Complacency / Overconfidence • Work-arounds / OOS instrumentation • Mind set (intention) • Hidden system response • Inaccurate risk perception • Unexpected equipment conditions • Mental shortcuts (biases) • Lack of alternative indication • Limited short-term memory
Task Demands
Individual Capabilities
· High workload (memory requirements)
· Simultaneous, multiple tasks
· Repetitive actions / Monotony
· Imprecise communication habits
· “Can do” attitude for crucial task
· Lack of or unclear standards
· Illness or Fatigue
Human Error – Pushed the wrong button on turnover..
Are you sure you want to do this?
Are you sure you want to unleash Hell and Panic and Cause Heart Attacks, Stress and all out Pandemonium?
You Need a Plan.
Forcing Functions
For many, it is more important to be heard and understood,
than agreed with.
PNNL Arc Flash
John Bumgardner, 20 Million under baseline, one year ahead of schedule
Two Choices after an Event (Unwanted Outcomes):
A. Investment
B. Cost
OK, now a brain exercise. While the brain has incredible capacity, it is also incredibly efficient.
To the point it takes the least path of resistance to problem solve.
A bat and a ball together cost $1.10
If the bat costs a dollar more than the ball, how much does the ball cost?
5 Cents
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