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What is Human & Organisational Performance (HOP)?
- 3. HOP is not a programme… …its an operating philosophy
- 6. Have you made an ERROR at work?
- 7. LOOKING BEYOND HUMAN ERROR “Underneath every simple, obvious story about ‘human error’, there is a deeper, more complex story about the organization” Dekker, 2014
- 9. EXPLANATION “The unknown brings with it danger, disquiet, worry - one’s first instinct is to get rid of these awkward conditions… …the first idea which can explain the unknown as known feels so good that it is ‘held to be true’.” Nietzsche, 1888
- 10. TO BLAME OR UNDERSTAND When you plant lettuce, if it does not grow well, you don't blame the lettuce. You look for reasons it is not doing well. It may need fertilizer, or more water, or less sun. You never blame the lettuce. Yet if we have problems with our friends or family, we blame the other person. But if we know how to take care of them, they will grow well, like the lettuce. Thích Nhất Hạnh
- 13. SYSTEMS THINKING Field Expert Involvement Local Rationality Just Culture Demand & Pressure Resources & Constraints Interactions & Flows Trade-offs Performance Variability Emergence Equivalence The View of People within the System System Conditions that Affect Work The Way the System Behaves System Outcomes
- 14. SIGNIFIERS “some sort of indicator, some signal in the physical or social world that can be interpreted meaningfully” Norman, 2011
- 15. LEARNING IS VITAL PRINCIPLE #4
- 16. is failure bad?
- 18. WORK AS PLANNED vs WORK IN PRACTICE Work as Planned Work in Practice “Workers are Masters of Complex Adaptive Behaviour” “masters of the blue line” Conklin & Edwards, 2018
- 19. THE DOMINANT ACCIDENT MODEL “No man ever steps in the same river twice, for it's not the same river and he's not the same man.” Heraclitus
- 20. THE SWISS CHEESE FALLACY The SCM does not provide a detailed accident model or a detailed theory of how the multitude of functions and entities in a complex socio-technical system interact and depend on each other. REASON ET AL., 2006
- 21. A ‘MESSY’ STORY fear of reporting weak signals system strengths resource constraints local factors change in plans incomplete proceduresunclear signals production pressure design shortcomings poor communication goal conflict tradeoffs adaption latent conditions system weaknesses flawed processes normal variability near misses data past successes personal factors surprises errors (Conklin, Edwards, Baker & Howe, 2017) EVEN T
- 23. OUR CHOICE… You can learn and improve or you can blame and punish. You cant do both. CONKLIN
- 24. R E S P O N S E S T O L O O K O U T F O R STOP & AVOID “You cant fix stupid” “If only they had…” “What were they thinking?” “Why did no one stop the work?” “Had they done a JSA?” DEVELOP “How did we make this situation more likely” “What is the organisations responsibility here?” “What can we learn from this?’’
- 25. DISCOVERING SAFETY uncertain interpretation of safe work feels too risky clearly not safe to do work feels overly cautious clearly safe to do work Conklin, 2012
- 26. AFTER AN EVENT safe to do work clearly ‘the right way’ “after the event, Safety is clear” Conklin, 2012 not safe to do work clearly ‘the wrong way’ EVEN T
- 27. PRESSURE TO FIX Time Information learning curve better solutions respond and contain effective learning “the pressure to fix… outweighs the desire to learn” Edwards, 2018
- 28. SLOW DOWN & LEARN
- 30. THANKYOU! Andy Shone, CEO Southpac International www.southpacinternational.com andy@southpac.biz
Editor's Notes
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- KEY POINTS: DELIVERY: REFERENCES: Hardware giant Bunnings is being roasted for imposing a radical change on its famous weekend sausage sizzles. And it all comes down to onions. Bunnings management has told community groups the onions must go on the bread first, ahead of the sausage. The hardware giant is taking the high moral ground and claiming health and safety has prompted the change. It says pieces of onion dropped by hungry shoppers have created “slipping hazards” outside its stores. Putting onions first, ahead of the sausage, would help avoid this, it said. 6th November 2018 Almost 200 of the 3,800 graves at Efford Cemetery have been deemed to be a hazard after a recent inspection. But the hazard signs have sparked outrage from families of those buried at the Plymouth site. Paul Ford's grandparents are buried at the cemetery, dismayed to find their names were covered. He told the Plymouth Herald: "Where they have put the placard you cannot see who has been buried there; it looks more like a building site. "I think it's disrespectful to cover up the names of the dead. If it was on the back it would be okay, but it's not. "They should have made more effort not to cover up the names. It's an eyesore.” In most cases where the graves were marked with the hazardous warning, the families were formally told in writing. However, those with family unable to be traced were tagged with yellow stickers. Others have since taken to social media to support Paul, with one writing: "I would go crazy if a sign was put on my dad's grave like this. "I agree place the sign on the back." Another added: "Surely there’s a better way of doing this. A sign by the entrance and a small yellow marker by the graves would have sufficed. "It’s turned what should be a peaceful place of rest and respect into looking like a building site. I’m all for health and safety but this is over the top!" A Plymouth City Council spokesman said: "We check each and every memorial in our cemeteries every five years for signs of defects that could make them dangerous to visitors. "An inspection is carried out by monumental masons and the memorial is tested for stability. "Our recent round of inspections showed that only five per cent of the 3,800 memorials that have been tested at Efford Cemetery this summer had defects. "The deed holder/owner of the grave is responsible for the memorial, so if a memorial is found unsafe and/or in need of repair we'll send a letter to the address we've got on record. "When this is not possible, we place a warning sign on the grave to advise the owner how to contact us to talk about options for repair. "More information can be found on the Burial and Cremation section of our website." INDIVIDUAL NOTES:
- KEY POINTS: HOP is not a programme and there is no end date We want to change the way you think It’s the 100 small things we have to change – all the minor tweaks to make Its about how you communicate and work with people DELIVERY: REFERENCES: INDIVIDUAL NOTES:
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- KEY POINTS: DELIVERY: Ask ‘have you made an error at work that’s made an impact on you that you feel comfortable sharing – write on your name card’ Trainer to discuss an error they have personally made REFERENCES: INDIVIDUAL NOTES:
- KEY POINTS: DELIVERY: REFERENCES: (Dekker, 2014, p. 5) Dekker, S. (2014). The Field Guide to Understanding ‘Human Error’ (3rd ed.). Farnham: Ashgate Publishing Limited. INDIVIDUAL NOTES:
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- KEY POINTS: Sydney Olympic Towers; Structural failures Media went on a witch hunt Blamed; Builder, Developer Engineers, Certifiers, Council “Psychological Explanation for This .—Tracing something unknown back to something known gives relief, soothes, satisfies, and furthermore gives a feeling of power. The unknown brings with it danger, disquiet, worry— one’s first instinct is to get rid of these awkward conditions. First principle: any explanation is better than none. Because it is basically just a question of wanting to get rid of oppressive ideas, we are not exactly strict with the means we employ to get rid of them: the first idea which can explain the unknown as known feels so good that it is ‘held to be true’. Proof of pleasure (‘strength’) as criterion of truth. —The causal drive is therefore determined and stimulated by the feeling of fear. The ‘why?’ is intended, if at all possible, not so much to yield the cause in its own right as rather a kind of cause —a soothing, liberating, relief-giving cause. The fact that something already known , experienced, inscribed in the memory is established as a cause, is the first consequence of this need. The new, the unexperienced, the alien is ruled out as a cause. So it is not just a kind of explanation which is sought as cause, but a select and privileged kind of explanation, the kind which has allowed the feeling of the alien, new, unexperienced to be dispelled most quickly and most often— the most usual explanations. —Result: one way of positing causes becomes increasingly prevalent, is concentrated into a system and ultimately emerges as dominant , i.e. simply ruling out other causes and explanations. —The banker’s first thoughts are of ‘business’, the Christian’s of ‘sin’, the girl’s of her love.” (Nietzsche, 2008, pp. 29-30) DELIVERY: REFERENCES: Nietzsche, F. (1998). Twilight of the Idols: A new translation oby Duncan Large. Oxford: Oxford University Press. INDIVIDUAL NOTES:
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- KEY POINTS: DELIVERY: add notes tying this into the Jalalabad crash REFERENCES: INDIVIDUAL NOTES:
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- KEY POINTS: DELIVERY: REFERENCES: (Norman, 2013, p. 64) Norman, D. (2011). Living with Complexity. London: The MIT Press. Norman, D. (2013). The Design of Everyday Things: Revised and Expanded Edition. London: The MIT Press. INDIVIDUAL NOTES:
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- KEY POINTS: Simple explanations = Pick your root cause The Messy Story = Accidents are emergent properties of a complex system. Attribution of a cause or root cause is a choice not an objective statement of fact. We are more interested in understanding how the various conditions coupled and combined. DELIVERY: REFERENCES: INDIVIDUAL NOTES:
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- KEY POINTS: DELIVERY: REFERENCES: Conklin, T. (2012). Pre-Accident Investigations: An Introduction to Organizational Safety. Boca Raton: CRC Press. INDIVIDUAL NOTES:
- KEY POINTS: DELIVERY: REFERENCES: Conklin, T. (2012). Pre-Accident Investigations: An Introduction to Organizational Safety. Boca Raton: CRC Press. INDIVIDUAL NOTES:
- KEY POINTS: DELIVERY: REFERENCES: Conklin, T. (2012). Pre-Accident Investigations: An Introduction to Organizational Safety. Boca Raton: CRC Press. INDIVIDUAL NOTES:
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