Todd-Conklin-preaccident investigation the podcast.pdf

investigación de accidentes

1. •CoonkCliWhl
Faeddhoaljn Coducj Todd Conklin
PreAccident Podcast

2. Human
Performance
Highly Reliable
Organizations
Todd Conklin PhD
Human Performance Improvement/ HRO
[email protected]

3. Never
take a sleeping pill
And a laxative
at the same time.
In any order…
Conklin

5. The Safety Journey So Far…
Time
A
c
c
i
d
e
n
t
s
Compliance
•Behaviors
•Policy/Rules
•Enforcement
Design
•Human Factors
•Process Safety
•Standardized
Systems Human
Performance
•New View
•Not Individual
•Organizational
issues Identified
Conklin
Fatality
Serious Event
•Not like others
•NO near misses
•Exist in success
•Understand work

6. Traditional
Safety
Conklin
1. Workers are the
problem to be fixed.
We fix safety by making
workers better.
2. We must tell workers
what to do and, perhaps
more importantly, not to
do.
3. Safety is the absence of
accidents.
Safety
Differently
1. Workers are not the
problem – They are the
problem solvers.
2. We don’t tell our
organizations what to
do – ask them what
they need.
3. Safety is not the
absence of accidents
– it is the presence of
capacity.
Preventing
things from

going w
rong.
M
aking sure
things go
right.

7. Safety is not
the absence of
Accidents.
Safety is the
presence of
Defenses.
Conklin
Capacity.

8. Conklin
Workers are as
safe as they need to be,
Without being too safe,
in order to be
productive.

9. #ljhWn•a$Fan%•!! Until They’re NOT..

10. Sharp End
Blunt End
Workers
Managers
Front-line
Supervisors
Leaders
Customers
Regulators
Company
Conklin
Highest
Influence
Over
System
Highest
Injury
Potential

11. Our work is
not
inherently safe.
People create safety
in practice.
Conklin

12. Parts of an Event
Conklin
Pre-Accident Investigations, Conklin 2013
3

13. Worker’s Don’t Cause
Failures.
Worker’s Trigger Latent
Conditions That Lie
Dormant In Organizations
Waiting for This Specific
Moment In Time.

14. Conklin

15. Shift your
thinking from
“Who Failed” to
“What Failed”
Conklin

16. Conklin

17. We must stop
seeing
workers as
problems to be fixed.
But, as Solutions
to be harnessed.
Conklin

18. Workers
Are Masters of
Complex Adaptive
Behavior…
Conklin
HOTDOG

19. *Workers Discover Safety While
Working…
Clearly Safe
to do Work
Clearly Not Safe
to do Work
The Gray Area:
Uncertain
interpretation
of Safe work
Conklin

20. 20
* After the Event, Safety is Clear…
Clearly Safe
to do Work
Clearly Not Safe
to do Work
Event
Conklin

21. Start
Of
Job
Hazard
Safety Understood:
Drift and Accumulation
Conklin
Work Execution
Improvement
Area
System Safety:
Fatality Prevention
Area

22. Is the juice
worth the
squeeze?
Conklin

23. Capacity
The Power of
Early
Hazard
ID
Identified
or Discovered
Problem
Conklin

24. Capacity
Identified
or
Discovered
Problem
The Power of
Early
Hazard
ID
Conklin

25. Its pretty simple…
You can

Blame & Punish
Or
Learn & Improve.
Conklin

27. Safety is not
the absence of
Accidents.
Safety is the
presence of
Capacity.
Conklin

29. •CoonkCliWhl
Faeddhoaljn Coducj Todd Conklin
PreAccident Podcast