Accident Investigations - Blame and Shame or Listen and Learn?
- 1. Deepwater Horizon Delusions Delusion of preventability and lineraity Examples of all accidents are preventable – lucky, Chemical factory Lac MeganBc Typical accident analysis – RCM steps Human error Killer Driver Human capability – ball girl, baseball player, The Accident Just culture repsonses AlternaBve methods Leadership link
- 2. “Blame ‘n shame” or ‘Listen and Learn” A Just approach to Accident InvesBgaBon NOSHCON September 2015 PresentaBon by Steve Woodward – SAFEmap InternaBonal
- 3. All accidents are preventable!! If we know the effect we can determine the cause If we know the cause we can eliminate it From this mindset it follows that…. We should never have an accident so why do we …well human error of course..
- 9. What was the cause?
- 10. Analyze and prevent accidents Eliminate risk-‐taking Enforce safety rules Educate in safe work procedures Engineer a safe work environment Measure safety performance Reward achievements
- 11. Zero
- 12. 1. The delusion of causa=on 2. preventability 2. The delusion of human error 3. The delusion of compliance 4. The delusion of consistency 5. The delusion of control 6. The delusion of quan=fica=on 7. The delusion of invulnerability
- 13. Probable Infrequent Remote Improbable Marginal Cri=cal Catastrophic
- 14. Preventability All accidents are preventable…
- 15. 12 dead, 42 injured
- 16. Photo 1. The Lac-Mégantic derailment site following the accident 1.2 Aftermath
- 18. …accident wai=ng to happen…
- 24. Driver Change over Thin tanker shells fail Air release Fire fighters shuts loco 911 call: Loco fire All leave scene No loco started Hand brakes fail Parked on .92% gradient Sets 7 handbrakes Reports smoke to authority
- 25. Rushing Complacent FaBgue Careless DistracBon Atude FrustraBon
- 27. Why? Why? Why? Why? Why? WYLFIWYWF hindsight
- 28. O_awa 18 September 2013 6 of 82 killed
- 30. Unknown risks Known risks
- 31. What? What? What? What?
- 32. Average level of posi=ve responses“All accidents can be prevented” 0 0 20 30 40 50 60 70 Percent Agree Linear (Percent Agree) More positive companies Best safety performance More negative companies Worst safety performance
- 35. The Chemical Factory 1 2 3 4 The Chemical Factory
- 36. 1000 40 1000 30 1000 20 1000 10
- 38. 1. The delusion of causa=on 2. The delusion of human error 3. The delusion of compliance 4. The delusion of consistency 5. The delusion of control 6. The delusion of quanBficaBon 7. The delusion of invulnerability
- 39. Risk management: where are the keys? “Virtual” risks Known risks
- 40. “Virtual” risks Known risks
- 41. Murphy’s Law according to Sidney Dekker “ Most of the time what will go wrong goes right …. ….until it doesn’t ”
- 42. Luck?
- 48. TradiBonal View of Determining Incident Causes Substandard Acts Substandard CondiBons Personal Factors Job Factors Incident Immediate Causes Underlying or Root Causes Management System Deficiencies Incident Causa=on Path Incident Inves=ga=on Path No Standard, Inadequate Standard, Non-‐Compliance “Finding the management system deficiencies that led to the incident”
- 50. Evolving View of Determining Incident Causes Incident Substandard Acts Substandard CondiBons Immediate Causes Human Factors Systemic Factors ContribuBng Factors Management System Deficiencies No Standard, Inadequate Standard, Non-‐Compliance Incident Causa=on Path Incident Inves=ga=on Path “Finding the management system deficiencies that led to the incident” Physical Factors
- 52. Full InvesBgaBon Limited Inves=ga=on
- 53. Inves=ga=on Risk Calculator Exercises • For each example provided, determine the following: a) The Actual risk level and PotenBal risk level; b) The recommended team size (supervisor only, small team or full team); and, c) The report type (limited invesBgaBon or a full invesBgaBon report)
- 55. "Ladies and gentlemen, thank you for flying with our Airline. Please make yourself comfortable..… For those of you si?ng on the right side of the plane..… please ignore our other airliner." A Cabin Announcement:
- 57. Anchor Error ! Severe accidents are overestimated − For example: nuclear, sharks, guns
- 58. Anchor Error
- 63. RISKcalculator Happens here often Seldom Quarterly Monthly Weekly Daily Continuous Fatalities Fatality Disability Serious (LTI) Medical First Aid Happened here previously Can happen here Heard of elsewhere Never heard of it Happened here recently PLEASE PRINT CLEARLY Likelihood Exposure Result Risk Level 9 8 7 6 5 4 3 2 1 Circle a numberDraw your lines above 2 VeryHigh High VeryLow LowMedium 6. Yes Final check, Risks Overlooked, Underestimated, Ignored, Rewarded? Do an act of safety. © 2009 SAFEmap International Pty. ✓ or ✖
- 64. Anchor Error
- 65. RISKcalculator Happens here often Seldom Quarterly Monthly Weekly Daily Continuous Fatalities Fatality Disability Serious (LTI) Medical First Aid Happened here previously Can happen here Heard of elsewhere Never heard of it Happened here recently PLEASE PRINT CLEARLY Likelihood Exposure Result Risk Level 9 8 7 6 5 4 3 2 1 Circle a numberDraw your lines above 2 VeryHigh High VeryLow LowMedium 6. Yes Final check, Risks Overlooked, Underestimated, Ignored, Rewarded? Do an act of safety. © 2009 SAFEmap International Pty. ✓ or ✖
- 67. RISKcalculator Happens here often Seldom Quarterly Monthly Weekly Daily Continuous Fatalities Fatality Disability Serious (LTI) Medical First Aid Happened here previously Can happen here Heard of elsewhere Never heard of it Happened here recently PLEASE PRINT CLEARLY Likelihood Exposure Result Risk Level 9 8 7 6 5 4 3 2 1 Circle a numberDraw your lines above 2 VeryHigh High VeryLow LowMedium 6. Yes Final check, Risks Overlooked, Underestimated, Ignored, Rewarded? Do an act of safety. © 2009 SAFEmap International Pty. ✓ or ✖
- 68. 1. The delusion of linearity 2. The delusion of human error 3. The delusion of compliance 4. The delusion of consistency 5. The delusion of control 6. The delusion of quanBficaBon 7. The delusion of invulnerability
- 72. As humans, we can (uniquely) be: ! Ina_enBve ! Incompetent ! ErraBc ! Biased ! ViolaBng • Lapsing • Forgetful • Unreliable • Inconsistent • Rigid and complacent...!
- 73. As humans, we can (uniquely) be: • Enduring • Compassionate • ImaginaBve • Sacrificing • Conquering • Heroic • Passionate • Inspirational • Intuitive • Adaptive
- 76. Miner in tunnel
- 88. Train Dilemma 4
- 91. Soldier picture
- 94. Pressures ExpectaBons At-‐risk CircumvenBon Perceptual Technical skills Incompetence Misjudgment CogniBve error Erroneous Risk IncenBves Safe Punishment Poor Design Risky RouBnes Delusions Calculated Careless Reckless Conformant Inten=onal IntenBonal Inadvertent
- 95. Change Train Discipline Coach Pressures ExpectaBons At-‐risk CircumvenBon Perceptual Technical skills Incompetence Misjudgment CogniBve error Erroneous Risk IncenBves Safe Punishment Poor Design Risky RouBnes Delusions Calculated Careless Reckless Conformant Inten=onal Discipline Sanc=on Warning Punishment Rebuke