Managing Human Risk

6,048 views

Published on

A Risk-Based Approach to Managing the Human Risk

Published in: Business

Managing Human Risk

  1. 1. A Risk-Based Approach to Managing the Human Risk an unclear and present danger Tony Muschara, CPT The Certified Performance Technologist (CPT) designation is awarded by the International Society for Performance Improvement (ISPI) to experienced practitioners in the field of organizational performance improvement whose work meets both the performance-based Standards of Performance Technology and application requirements. For more information, visit www.certifiedpt.org Copyright 2010 by Muschara Error Management Consulting, LLC
  2. 2. Managing the Human Element ―You cannot manage what you do not understand.‖ -- Elliot Jacques, The Requisite Organization Human element logo adapted from Dow Chemical: http://www.dow.com/hu/. Copyright 2010 by Muschara Error Management Consulting, LLC 2
  3. 3. What’s the Common Cause?  Challenger (7) / Columbia (7)  Texas City (15)  Chernobyl (>56)  Kansas City Hyatt (114)  Piper Alpha (167)  Herald of Free Enterprise (186)  Tenerife (583)  Bhopal (>2200) Copyright 2010 by Muschara Error Management Consulting, LLC 3
  4. 4. The Real Hazard to Safety & Quality “An unclear and present danger!” Threats to Safety and Quality “We have met the enemy … and he is us.” -- Walt Kelly Errors happen! Copyright 2010 by Muschara Error Management Consulting, LLC 4
  5. 5. Touching = Risk  Assets  Equipment, services, deliverables, time, information, people, knowledge, money, etc.  Hazard  Human Fallibility – Human Error  Exposure  ―Touching‖ assets  Risk  Likelihood (frequency of occurrence)  Consequences (severity of occurrence)  Event  Accident, Incident, Mishap, ‗D‘ Words 5 Copyright 2010 by Muschara Error Management Consulting, LLC 5
  6. 6. Purpose of Hu Management To protect products, servi ces, assets, an d people from human error Copyright 2010 by Muschara Error Management Consulting, LLC 6
  7. 7. Types of Error  Active Errors  Physical, observable actions that change equipment, system or facility state, resulting in immediate unwanted outcomes (harm)  Latent (sleeping) Errors  an action, inaction or decision that creates an unwanted condition (weakness) but goes unnoticed at the time, causing no immediate, apparent harm to the work, facility, or personnel Latent weaknesses accumulate! 7 Copyright 2010 by Muschara Error Management Consulting, LLC 7
  8. 8. Latent System Weaknesses (LSW) Undetected deficiencies in facilities, processes, or values that create job-site conditions that provoke error and/or degrade the integrity of defenses. Latent Error – An act or decision inconspicuous to the individual that establishes a latent condition. Copyright 2010 by Muschara Error Management Consulting, LLC 8
  9. 9. Be Aggressive! The causes of tomorrow‘s events exist today! Latent System Weaknesses Accumulate! Copyright 2010 by Muschara Error Management Consulting, LLC 9
  10. 10. Severity of Hu Events in Nuclear* Number of Number of Population Latent Errors Active Errors Operations 31 41 Maintenance 54 4 Engineering 67 3 Management 68 2 Totals 220 50 *U.S. NRC, NUREG/CR-6753, Review of Findings for Human Error Contribution to Risk in Operating Events, August 2001. Copyright 2010 by Muschara Error Management Consulting, LLC 10
  11. 11. Latent System Weaknesses in Events*  Not correcting known problems; accepting degraded equipment  Inadequate involvement in risk-significant activities  Structure / processes impede proper practices  Increase in volatility of operations  Reduction in reserves and options for technicians  Ineffective self-assessment and corrective action processes  Strained resources  Design-related deficiencies  Inadequate pre-job briefings  Procedures incomplete, unclear, or incorrect *U.S. NRC, NUREG/CR-6753, Review of Findings for Human Error Contribution to Risk in Operating Events, August 2001. Copyright 2010 by Muschara Error Management Consulting, LLC 11
  12. 12. Risk Management Strategy for Hu 1. Minimize the frequency of occurrences:  Reduce active errors at critical touch points  Reduce drift in standards with safe practices  Operationally oriented (touching) 2. Minimize the severity of occurrences:  Reduce effects of latent errors (conditions)  Minimize the accumulation of latent system weaknesses (faulty defenses)  Organizationally oriented (managing system health) Copyright 2010 by Muschara Error Management Consulting, LLC 12
  13. 13. Managing Hu Risk* The application of managerial and technical skills in a systematic, forward-looking manner to identify and control the human hazard to key assets throughout the life cycle of a project, product, service, program, or work activity. * Source: System Safety Course, FAA Academy Copyright 2010 by Muschara Error Management Consulting, LLC 13
  14. 14. Hu Event Chain* Learning 1 2 3 Organization / Local Management Factors B RL RM Latent Weaknesses Flawed Defenses Event - An unwanted outcome, triggered by human error, that results in the serious impairment or B – Behavior termination of an asset’s ability to perform its RL – Results (local: individual) desired function, damage to the environment, or RM – Results (mission: many) serious injury to people *Reason, J. (2003), Managing Maintenance Error, p.90. Copyright 2010 by Muschara Error Management Consulting, LLC 14
  15. 15. Reducing Error at Critical Steps Copyright 2010 by Muschara Error Management Consulting, LLC 15
  16. 16. Integrating Hu Work Execution Process into Operations Asset & Hazard Positive control Touching needed here! Preparation Execution Feedback Local Factors Operational Organizational Organization (system) Copyright 2010 by Muschara Error Management Consulting, LLC 16
  17. 17. Local Factors: Performance Drivers Requirements, Expectations, & Feedback Tools, Resources, & Job-site Environment Incentives & Organization / Disincentives Worker Management System Behavior Knowledge & Skills Capacity & Readiness Personal Motives, Expectations, & Preferences Copyright 2010 by Muschara Error Management Consulting, LLC 17
  18. 18. Local Factors* 1. 2. 3. Task & Environmental Requirements, Tools, Resources, Incentives Factors Expectations, and and and Feedback Job-Site Disincentives job-specific requirements, an environment of rewards and 35% 29% 11% standards, guidance, job-related external conditions sanctions explicitly or implicitly reinforcement, coaching, or affecting performance of the job associated with the job correction on what one is supposed to do and how well 4. 5. 6. Human & Knowledge Capacity Personal Individual and And Expectations, Factors Skills Readiness Motives, and Preferences individual‘s basic/specialized individual‘s personal motivation, understanding of technical individual‘s physical, mental, 11% concepts, theories, systems, construction, fundamentals, including skills, proficiency, and experience 8% and emotional factors influencing individual‘s ability / capacity to perform a job 6% anticipations, and preferences related to needs for security, achievement, affiliation, and control *INPO 06-003, Human Performance Reference Manual, p.91. Copyright 2010 by Muschara Error Management Consulting, LLC 18
  19. 19. Positive Control* What is intended to happen is what happens and that is all that happens. * Source: Institute of Nuclear Power Operations (2006), Human Performance Reference Manual (INPO 06-003). Copyright 2010 by Muschara Error Management Consulting, LLC 19
  20. 20. Probability of Success for 100 Actions P (success) = .99100 Copyright 2010 by Muschara Error Management Consulting, LLC 20
  21. 21. Nuclear Explosive Operations* “Critical Step” “Hazardous Step” ―Procedure step, if ―Procedure step that, if skipped or performed performed incorrectly, incorrectly, will increase has a potential to the likelihood of a high- immediately result in a energy detonation …, at dominant high-energy some later step in the detonation, …‖ procedure.‖ * Fischer, S. et al (1998), ―Identification of Process Controls for Nuclear Explosive Operations. ― Copyright 2010 by Muschara Error Management Consulting, LLC 21
  22. 22. Critical Step* Any step, action or previous actions that, if performed improperly, will trigger immediate, irreversible harm. * Source: Institute of Nuclear Power Operations (2006), Human Performance Reference Manual (INPO 06-003). Copyright 2010 by Muschara Error Management Consulting, LLC 22
  23. 23. Excellence is NOT Good Enough! ex⋅cel⋅lence –noun 1. the fact or state of excelling; superiority; eminence in a particular domain 2. condition of excelling 3. something in which one excels Is “best in class” good enough? 23 23 Copyright 2010 by Muschara Error Management Consulting, LLC
  24. 24. Mental Skills (Hu Tools)* Definition Skill Domains Cognitive skills that  Situation Awareness complement worker‘s  Communication technical skills; a  Decision Making discrete set of cognitive behaviors to  Teamwork act with less chance of  Stress / Fatigue error—promoting safe Management and efficient  Leadership performance 24 * Flin, R., et al, (2008), Safety at the Sharp End, A Guide to Non-Technical Skills, p. 1. Copyright 2010 by Muschara Error Management Consulting, LLC 24
  25. 25. Adaptive Strategies: Mental Skills Performance Modes: Mental Skills (Hu Tools)  Skill-based provide people a discrete set of cognitive behaviors to  Rule-based help them perform their  Knowledge-based actions more reliably—less chance of error. Current Knowledge They help focus attention by slowing down the cognitive cycle (shown at left). Unfolding Actions Situation Changes Copyright 2010 by Muschara Error Management Consulting, LLC 25
  26. 26. Worker Contribution to Safety* Worker Contribution to Safety Safety Barriers Hu Tools Improvisation Lo Hi Organization’s Anticipation of Risk * Source: Svensen, O., et al. (Eds.) (2006), Nordic Perspectives on Safety Management in High Reliability Organizations: Theory and Applications (NKS-131), Stockholm University, Sweden; p.154. Copyright 2010 by Muschara Error Management Consulting, LLC 26
  27. 27. Means Workers Contribute to Safety*  Barriers – preventing a set of predefined unwanted events from occurring and/or means to reduce the consequences of such events, e.g., procedures, pre-job briefing, placekeeping  Mental Skills (Hu tools) – protecting against dangers not explicitly predefined but likely to occur; subjective, real-time evaluation of the danger associated with the situation at hand, e.g., chronic uneasiness, self-checking, questioning attitude, situation awareness  Improvisation – fabricating a plan to address a danger using what is conveniently on hand, especially when the danger deviates radically from what has been anticipated, e.g., conservative decision-making, stop when unsure * Source: Svensen, O., et al. (Eds.) (2006), Nordic Perspectives on Safety Management in High Reliability Organizations: Theory and Applications (NKS-131), Stockholm University, Sweden; p.154. Copyright 2010 by Muschara Error Management Consulting, LLC 27
  28. 28. Mental Skills (Hu Tools) 1. Pre-job & Post-job briefings 2. Take a Minute 3. Self-checking (STAR) & Peer-checking 4. Questioning Attitude & Stop When Unsure 5. Rule of Three (conservative decision-making) 6. Assertive Statement 7. Three-part communication 8. Placekeeping (procedure use) 9. Flagging & Blocking 10. Concurrent & Independent Verification Copyright 2010 by Muschara Error Management Consulting, LLC 28
  29. 29. Managing Defenses Copyright 2010 by Muschara Error Management Consulting, LLC 29
  30. 30. Error Rate Error Rate Reduction Before Mental Skills After Random Causes Time Copyright 2010 by Muschara Error Management Consulting, LLC 30
  31. 31. Severity Pyramid* Fatality 1 First-aid Cases 10 Equipment Damage 30 Near Misses & Errors 600 * Source: Frank Bird, Jr., Practical Loss Control Leadership, Det Norske Veritas, 1969. Copyright 2010 by Muschara Error Management Consulting, LLC 31
  32. 32. Error Management Hierarchy 1. Eliminate the activity. 2. Prevent error. 3. Catch error. 4. Detect defect. 5. Mitigate the harm. Prevention – Detection – Correction --Dr. Chong Chiu, Performance Improvement International, Inc. Copyright 2010 by Muschara Error Management Consulting, LLC 32
  33. 33. Defenses  Engineered Controls  Do not depend on people to perform function  Design – eliminate / substitute the task (task allocation)  Safety Devices – passive and active controls or barriers  Administrative Controls  Warning Devices – detect and warn, labels  Procedures, job aids, Hu tools, training, PPE  Oversight Controls  Supervisory practices  Inspection and monitoring  Audits and assessments  Cultural Controls  Leadership  Values, beliefs, assumptions 33 Copyright 2010 by Muschara Error Management Consulting, LLC 33
  34. 34. Defenses and Error Management Type Engineered Admin Oversight Cultural Purpose Defenses Defenses Defenses Defenses Eliminate (substitute) Prevent Catch Detect Mitigate Purpose – what you want to do in Hu Type – how you want to do it Copyright 2010 by Muschara Error Management Consulting, LLC 34
  35. 35. Defenses: Controls and Barriers Controls: Barriers: Measures that Measures that protect guide, coordinate, or against harm by limiting regulate or impeding the free performance movement or flow of information, objects, substances, or energy Engineered  Administrative  Oversight  Cultural Copyright 2010 by Muschara Error Management Consulting, LLC 35
  36. 36. JHA – HuRM Contrasted Job Hazard Analysis Hu Risk Management (JHA) (HuRM) 1. Identify job steps 1. Identify key assets 2. Identify hazards and hazards 3. Define control measures 2. Identify risk-important touchpoints 3. Assess risk at critical steps 4. Determine controls and barriers for each critical step 5. Identify required organizational factors to sustain defenses Copyright 2010 by Muschara Error Management Consulting, LLC 36
  37. 37. Hu Risk Management Process* Pinpoint Assets Identify TouchPoints Assess the Risk Identify Controls and Barriers Prepare  Execute  Feedback Anticipate – Monitor – Respond – Learn Implement Defenses * Adapted from INPO, Human Performance Tools for Managers and Supervisors, 2007. Copyright 2010 by Muschara Error Management Consulting, LLC 37
  38. 38. Organizational Design ―It is impossible to manage any organization solely by means of mindless control systems that depend on rules, plans, routines, …for correct performance. No one knows enough to design such a system so that it can cope with a dynamic environment.‖ -- Karl Weick Authors: Managing the Unexpected Copyright 2010 by Muschara Error Management Consulting, LLC 38
  39. 39. High Reliability Organization (HRO) HROs are: ―Organizations [that] operate under trying conditions yet perform relatively event-free over a long period of time, making consistently good decisions that result in high quality and reliable operations.‖ -- Karlene Roberts U.C. Berkeley Roberts, K. (2003), ―HRO has Prominent History,‖ Anesthesia Patient Safety Foundation Newsletter, Vol. 18, No. 1, pp.1-16. Copyright 2010 by Muschara Error Management Consulting, LLC 39
  40. 40. Properties of Resilient Organizations*  Anticipate – assess risk  Monitor – asset‘s exposure to human  Respond – positive control at critical touch points  Learn – report, assess, analyze, trend, correct, and improve (change behavior) Chronic Unease * Source: Hollnagel, et al., Resilience Engineering, (2006), p.350, and Resilience Engineering Perspectives, Vol. 2, (2009), pp.117-133. Copyright 2010 by Muschara Error Management Consulting, LLC 40
  41. 41. Organizational & Management System Risk Factors*  Communication  Housekeeping Practices  Management and  Continuous Leadership Practices Improvement  Organizational Goals  Culture and Priorities  Expectations and  Policy & Strategy Standards  Procedures  Hardware and and Processes Design  Training  Hazard Controls  Work Management  Human Resources * Source: Greoneweg, J., Controlling the Controllable Copyright 2010 by Muschara Error Management Consulting, LLC 41
  42. 42. Example Latent System Weaknesses Work Management Training  Lack of coordination  No task qualification between work groups program working in same physical  Ineffective OJT/TPE space.  Lack of management  Insufficient staffing for involvement scheduled activity  Not adapting training to  No hazard analysis done changes in equipment during planning  Not incorporating lessons  No review of schedule by learned into training affected organizations materials Copyright 2010 by Muschara Error Management Consulting, LLC 42
  43. 43. Challenges to Managing Hu Risk  Can’t afford to learn only from operational events  Fewer events  Too costly  Too late  Must learn more from small events  Trend analysis  Historical data  Near Hits  And non-events (real-time operations)  Human performance (local factors & behavior)  Assessments (self and independent)  System health – improve resistance to accidents and events Copyright 2010 by Muschara Error Management Consulting, LLC 43
  44. 44. Improving System Health Internal Methods External Methods  Field observations  Industry operating  Post-job reviews experience reports  Reporting  Benchmarking  Self-assessments  Independent oversight  Metrics and trending  Common Cause Analysis  Surveys  Root cause analysis  Effectiveness Reviews Copyright 2010 by Muschara Error Management Consulting, LLC 44
  45. 45. 5-Tier Approach – Finding LSWs 1. Reporting 2. Observation and Coaching 3. Self-Assessment and Trending 4. Operating Experience and Benchmarking 5. Causal Analyses “Eliminating latent [system weaknesses] is the most effective way to manage human error.” --Jop Groeneweg Author: Controlling the Controllable Copyright 2010 by Muschara Error Management Consulting, LLC 45
  46. 46. Management’s Role in Hu Copyright 2010 by Muschara Error Management Consulting, LLC 46
  47. 47. Dr. Ignaz Semmelweis  Vienna General Hospital‘s obstetrical clinic  Maternal mortality rate in midwifery unit three times lower than doctor‘s unit  Doctors often moved directly from autopsies in morgue to maternity ward  Maternal death rates dropped from 18.3% to 1.3% with new measure  Current compliance around 60%  What was the new defense measure? 47 Copyright 2010 by Muschara Error Management Consulting, LLC 47
  48. 48. Drift and Accumulation* Hi Expectations Safety Drift Current Practice Real Safety Margin Danger Accumulation Hazards/Threats Lo * Adapted from Dekker, S. (2007), The Field Guide to Understanding Human Error. Time Copyright 2010 by Muschara Error Management Consulting, LLC 48
  49. 49. Chronic Sense of Uneasiness* An attitude of Q u e s tio n in g A ttitu d e M e te r mindfulness regarding one‘s H e a lth y U n e a s in e s s / W a rin e s s /A le rtn e s s To capacity to err and in ta e er r / o To C o e rt nc nsu Su ai re n / the presence of U U hidden threats; preoccupation with failure “When you stop being scared, you start making mistakes.” -- unknown * Source: Questioning Attitude Meter was developed by my friend John Summers. Copyright 2010 by Muschara Error Management Consulting, LLC 49
  50. 50. Mindfulness A rich awareness of the context of one‘s situation characterized by the following: 1. Understand the ―big picture‖ of ongoing operations 2. Know what is important to safety, quality, and reliability 3. Know how to respond before or after losing control 4. Sensitive to emerging threats and dangers 5. Questioning attitude toward everything; nothing is always as it seems Copyright 2010 by Muschara Error Management Consulting, LLC 50
  51. 51. Work as Imagined How managers IMAGINE work is being done ∆ 51 How work IS done Copyright 2010 by Muschara Error Management Consulting, LLC 51
  52. 52. Management’s Role  Integrate ―Anticipate, Monitor, Respond, and Learn‖ properties into risk-important processes and activities  Leadership – ―chronic uneasiness‖  Oversight – observation: eliminate gap between work as imagined and work as done; aware of current Hu threats to safety and product quality  Organizational – optimize system health (minimize accumulation of latent system weaknesses)  Operational – counteract drift especially at critical steps; coaching Copyright 2010 by Muschara Error Management Consulting, LLC 52
  53. 53. Oversight of Hu – Operational 3 Questions to Ask Line Managers 1. What are your Hu vulnerabilities (Drift)? 2. What are you doing about them? 3. Are you successful controlling the vulnerabilities? 1 Local 3 2 Factors 4 5 6 B Copyright 2010 by Muschara Error Management Consulting, LLC 53
  54. 54. Management Disengaged – Effects  People no longer fear error; complacency grows  Mindlessness grows; the effectiveness of anticipation, monitoring, and responding declines.  Accepted practices drift from expectations; production and efficiency eclipse safety and reliability in importance.  Latent system weaknesses accumulate unhampered; threats and hazards proliferate and defenses erode.  Communication and learning diminish.  Incidents grow in frequency and severity. Copyright 2010 by Muschara Error Management Consulting, LLC 54
  55. 55. Effort vs. Importance* Latent System Weaknesses Human Error Equipment Failure Effort Expended Importance (currently) (actual) * Adapted from Kletz, T. (2001), An Engineer’s View of Human Error (3rd ed.); p.127.. Copyright 2010 by Muschara Error Management Consulting, LLC 55
  56. 56. Risk Management Strategy for Hu 1. Minimize the frequency of occurrences:  Reduce active errors at critical touch points  Reduce drift in standards with safe practices  Operationally oriented (touching) 2. Minimize the severity of occurrences:  Reduce effects of latent errors (conditions)  Minimize the accumulation of latent system weaknesses (faulty defenses)  Organizationally oriented (managing system health) Copyright 2010 by Muschara Error Management Consulting, LLC 56
  57. 57. Questions and Comments 4724 Outlook Way Marietta, Georgia 30066 678-665-2095 tmuschara@muschara.com http://www.muschara.com Copyright 2010 by Muschara Error Management Consulting, LLC 57

×