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NSC2017_Humans in the Machine_The RAD Group

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Presentation at the 2017 NSC Congress in Indianapolis, IN.

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NSC2017_Humans in the Machine_The RAD Group

  1. 1. congress.nsc.org Session # 57 
 Humans in the Machine: Enhancing safety as operations become more complex
 Phillip Ragain
  2. 2. Humans in the Machine Overview ‣ The Role of People: Evolving Frameworks ‣ A Linear View (Behavioral) ‣ A Systems View (Complexity & Human Factors) ‣ The Human Role in Complex Systems ‣ A Human Factors Analysis of Intervention © 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.
  3. 3. “88% of all accidents, injuries, and illnesses are the result of man-failure.” - Herbert William Heinrich (1931) Evolving Frameworks “The leading cause [of accidents and injuries] is the at-risk behavior of employees themselves. - Watson, et al (2005) A Linear View © 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.
  4. 4. Evolving Frameworks BA System of Operations Linear View Sees behavior as affecting the safety of the system © 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.
  5. 5. Systems View Sees people as part of the system Evolving Frameworks © 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.
  6. 6. Systems View Sees people as part of the system Evolving Frameworks © 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.
  7. 7. Systems View Two forces driving a “paradigm shift” ‣ Complexity Theory ‣ Human Factors Evolving Frameworks © 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.
  8. 8. Complexity Theory Evolving Frameworks
  9. 9. Complexity Theory $ Evolving Frameworks
  10. 10. Human Factors Evolving Frameworks
  11. 11. Human Factors Evolving Frameworks The study of how people interact with their physical, technological, organizational and social environment © 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.
  12. 12. Human Factors Evolving Frameworks Cognition occurring in a specific context is itself a complex system.
  13. 13. Human Factors Evolving Frameworks Human behavior is not the cause of incidents. It is part of a larger system failure.
  14. 14. A Stabilizing Force The Reality The production context is . . . ‣ Complex ‣ Dynamic ‣ Unpredictable © 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.
  15. 15. ‣ Limited in Scope ‣ Slow to Change ‣ Necessary but Insufficient The Problem Mechanical and administrative barriers are . . . A Stabilizing Force © 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.
  16. 16. A Stabilizing Force The “Catch” The more mechanical and administrative barriers introduced into the system, the more complex and difficult to monitor things become. © 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.
  17. 17. The Solution We need something that is . . . A Stabilizing Force ‣ Dynamic ‣ Creative ‣ Ubiquitous (throughout the system) © 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.
  18. 18. The human body is an analogue of other complex systems. © 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC. A Stabilizing Force
  19. 19. While partially direct by an executive function, the system’s elements are largely autonomous. This can create unintended or undesired outcomes. © 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC. A Stabilizing Force
  20. 20. Because of the interconnectedness of different systems, deterioration in one part can spread throughout the system. © 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC. A Stabilizing Force
  21. 21. The protections integrated into this system are similar to what is needed in industrial systems. © 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC. A Stabilizing Force
  22. 22. A Stabilizing Force Linear View Humans destabilize systems that are engineered to be safe. Systems View Humans are uniquely capable of stabilizing complex systems. System of Operations
  23. 23. ‣ Awareness ‣ Risk Aversion ‣ Intervention ‣ Adaptation (Learning & Reporting) Humans as a Stabilizing Force in Complex Systems A Stabilizing Force © 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.
  24. 24. ‣ Awareness ‣ Risk Aversion ‣ Intervention ‣ Adaptation (Learning & Reporting) Humans as a Stabilizing Force in Complex Systems A Stabilizing Force © 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.
  25. 25. A Stabilizing Force Most people take this responsibility very seriously and believe that they would speak up. But people intervene only 39% of the time. Intervention. © 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.
  26. 26. A Stabilizing Force We can use a human factors approach to understand why people do not intervene. © 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.
  27. 27. A Stabilizing Force The Context Effect There are factors in the production context that often “override” people’s belief that they should intervene. © 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.
  28. 28. A Stabilizing Force Inhibiting Forces: Bystander Effect The more people there are, the less likely we are to speak up. © 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.
  29. 29. A Stabilizing Force Inhibiting Forces: Production Pressure It can change the way we see the world. © 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.
  30. 30. A Stabilizing Force Inhibiting Forces: Deference to Authority The presence of an authority figure inhibits intervention. © 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.
  31. 31. A Stabilizing Force Increasing Intervention Rates Simply being aware of these inhibiting forces decrease their influence. © 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.
  32. 32. ‣ Awareness ‣ Risk Aversion ‣ Intervention ‣ Adaptation (Learning & Reporting) Humans as a Stabilizing Force in Complex Systems A Stabilizing Force © 2016, The RAD Group, LLC. All Rights Reserved. Unauthorized reproduction or distribution, in part or in whole, is forbidden unless permitted in writing by The RAD Group, LLC.
  33. 33. congress.nsc.org We rely on you to help evaluate Congress sessions as we strive to increase presentation and topic quality, so please take the time to fill out the short survey. Session # 57 
 Humans in the Machine: Enhancing safety as operations become more complex
 Phillip Ragain

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