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The Luck Factor: Mistakes That (Sometimes) Get Us Hurt
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The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

Jun 13, 2018

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Page 1: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

The Luck Factor:Mistakes That (Sometimes) Get Us Hurt

Page 2: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

2The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

How many mistakes have you made?

Page 3: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

3The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

Two types of mistakes(some are intentional and others unintentional)

• Not doing something that you should have

done

Page 4: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

4The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

Don’t like to do?

• Take out trash

• Dentist

• Car to shop

• Doctor

• In-laws

• Gym

Page 5: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

5The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

Inserting machine

• Initially no cover on opening wheel

The Machine Operator

also made a mistake…

not looking for,

or thinking about,

line-of-fire potential

as he was moving We obviously had an equipment issue

due to the unguarded rotating shaft

and opening wheel

Page 6: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

6The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

• Manufacturer

designed a guard

for the machine

• An engineering

control to prevent

accidental contact

Inserting machine

Page 7: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

7The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

One of the most common mistakes

people make on a regular basis

is not looking at what you’re doing

or where you’re going,

(or not thinking about it either)

Page 8: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

8The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

What’s the #1 thing to take people’s

eyes off the task they’re doing?

Page 9: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

9The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

• Not doing something that you should have

done

• Doing something you should not have

done

Two types of mistakes(some are intentional and others unintentional)

Page 10: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

10The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

Page 11: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

11The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

Sometimes mistakes cause…

• Performance problems

Page 12: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

12The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

Recognizing a

performance

mistake at

18,000 feet… Columbus

Page 13: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

13The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

Page 14: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

14The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

Recognizing a

performance

mistake at

18,000 feet…

Cincinnati

Columbus

Page 15: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

15The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

CMH

CVG

Page 16: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

16The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

Sometimes mistakes cause…

• Performance problems

• Embarrassment

Page 17: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

17The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

Not All Errors Cause Injuries

Page 18: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

18The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

Sometimes mistakes cause…

• Performance problems

• Embarrassment

• Quality or productivity issues

Page 19: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

19The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

Sometimes mistakes cause…

• Performance problems

• Embarrassment

• Quality or productivity issues

• Equipment damage

Page 20: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

20The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

Sometimes mistakes cause…

• Performance problems

• Embarrassment

• Quality or productivity issues

• Equipment damage

• Increased scrap and rejects

Page 21: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

21The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

Sometimes mistakes cause…

• Performance problems

• Embarrassment

• Quality or productivity issues

• Equipment damage

• Increased scrap and rejects

• Or even injuries

Page 22: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

22The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

What if it were your job to cause errors by others?

1

Page 23: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

23The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

Does Rushing at work cause mistakes?

Page 24: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

24The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

1 2

What if it were your job to cause errors by others?

Page 25: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

25The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

What about Frustration at work?

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26The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

1 2 3

What if it were your job to cause errors by others?

Page 27: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

27The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

Page 28: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

28The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

What about Fatigue at work?

Page 29: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

29The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

2011 FAA studyAir Traffic Controller Chronic Fatigue

• Nearly 20% of controllers committed “significant errors”

in the previous year

– Ex - Bringing planes too close together

– Over 50% of errors attributed to fatigue

• Over 60% of controllers said they had either fallen

asleep or experienced a lapse of attention driving to/from

midnight shifts

Source – Associated Press 8/10/15

Page 30: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

30The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

2011 FAA studyAir Traffic Controller Chronic Fatigue

• Schedules worked by 76% of controllers led to chronic

fatigue, creating pressure to fall asleep

• “Even with 8 to 10 hours of recovery sleep, alertness

may not recover to the full rested baseline level…”

Source – Associated Press 8/10/15

Page 31: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

31The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

What about Fatigue at your facility?

Page 32: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

32The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

Could Complacency also play a role in our mistakes?

Page 33: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

33The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

What about Complacency at work?

Page 34: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

34The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

Errors (which cause)States (cause)

Hazards

Less Risk (to become)

Hazards with a

critical error

More Risk

to become

Is there a discernable pattern?

Copyright © 2017 by Electrolab Limited. All Rights Reserved.

SafeStart is a registered trademark of Electrolab Limited.

Page 35: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

35The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

Will the “hierarchy of controls” approach eliminate all mistakes?

• Engineering Controls

– Guarding, separation by space, barriers, interlocks, and etc.

• Administrative Controls

– Policies, procedures, JSAs, and etc.

• PPE

– Safety glasses, slip resistant shoes, hearing protection, FR

clothing, and etc.

Page 36: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

36The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

Development of Personal Safety Skills

• Self-Trigger on the State or Amount of

Hazardous Energy

• Analyze Close Calls

• Look at Others for the Patterns that Increase

the Risk of Injury

• Work on Habits

Copyright © 2017 by Electrolab Limited. All Rights Reserved.

SafeStart is a registered trademark of Electrolab Limited.

Page 37: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

37The Luck Factor: Mistakes That (Sometimes) Get Us Hurt

Could our job be a bit easier?

• Develop Personal Safety Skills

• Which in turn impact a wide range KPIs(Key Performance Indicators)

• Does “selling safety” becomes easier?

Page 38: The Luck Factor - VPPPA, Inc. Luck Factor: Mistakes That (Sometimes) Get Us Hurt 3 Two types of mistakes (some are intentional and others unintentional) •Not doing something that

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