Workshop C Why Smart People Do Stupid Things: Recognizing & - - PDF document

Workshop C

Why Smart People Do Stupid Things: Recognizing & Correcting Behavior that Puts People in Harm’s Way … Incident Investigations, Root Cause & Corrective Actions That Work

Tuesday, March 21, 2017 9:45 a.m. to 11 a.m.

Biographical Information Richard Cutrell 2020 Bruck Street, Columbus, Ohio 43207 614-443-0241 RichardCutrell@FranklinInternational.com Richard Cutrell has worked in the EHS field for more than 28 years. He has EHS experience in heavy manufacturing, cold storage/distribution, railroad tank car industry, and is currently the Corporate EHS Manager for Franklin International in the chemical manufacturing industry. Mr. Cutrell has managed facilities that are covered by PSM, RMP, and managed in both union and non-union workforces. For the past 10 years, he has been a member of the Chemical Emergency Preparedness Advisory Council’s (CEPAC) Hazard Analysis Committee for Franklin County, Ohio. He has conducted EHS presentations at several MEC Symposiums, for the Franklin County LEPC, and other area businesses. Mr. Cutrell has degrees in Mechanical Engineering (Clark State Community College) and Chemistry (Urbana University). He has also received Class I Wastewater Operator Certification from the Ohio EPA and is a Six Sigma Black Belt Champion. According to legend, in 1997, under the tutelage of Mike Carnell from Six Sigma,

• Mr. Cutrell and his Black Belt Candidate Robert Carpenter were the first people to identify injuries as

“defects” in a Six Sigma Black Belt Certification project. Michael J. Freeman, CIH, CSP, CHMM 173 Brushwood Dr., Loveland, OH 45140 513-444-7355 Fax: 513-672-0340 mfreeman12@cinci.rr.com Mike Freeman is an EHS professional with over 25 years of experience. This experience ranges from general industry and manufacturing to global management of dispersed workforces. Currently, Mr. Freeman is the North American EHS Manager for GE Water and Process Technologies. In this role, he leads a staff dedicated to insuring EHS excellence with the field workforce. In general industry and manufacturing, Mr. Freeman has managed EHS programs at a manufacturing facility as well as leading multiple sites in a corporate level capacity. Additionally, Mr. Freeman has spent much of his professional life in consulting. This consulting has been for clients from all sectors. This consulting experience has included environmental site assessments, industrial hygiene assessments, auditing, program development and training. Mr. Freeman holds a bachelor’s degree in environmental health from Indiana

• University. Mr. Freeman is certified in the comprehensive practice of industrial hygiene, in

comprehensive practice as a safety professional as well as hazardous materials management. Christina L. Whitehead, CSP 201 W. Crescentville Rd. Cincinnati, Ohio 45246 513-400-7183 christina.whitehead@ge.com Christina Whitehead has15 years of experience as an EHS professional and almost 20 years in manufacturing and general industry. Currently, Ms. Whitehead is the Lean, Materials, and Delivery Leader for GE Aviation Engine Services in Springdale, OH. In this role, she leads an hourly and salaried staff dedicated to insuring safety, quality and delivery within a 550 person overhaul and repair shop. Ms. Whitehead has almost 6 years with GE Aviation, during her time with GE, she started as the EHS Leader for Evendale Manufacturing Operations, then took a dual role as a QS/ISO Rep and a Quality Control Engineer, then as a Lean Leader before transitioning over to her most current role. Prior to GE, Ms. Whitehead worked for as an EHS consulting firm for 5 years, and an EHS Manager for Amazon in Wilmington, DE. During her time as a consultant, she conducted EHS audits, site assessments, conducted EHS training such as OSHA 10 & 30 Hour, HAZWOPER, LOTO, RCRA/DOT etc. and acted as an EHS site manager. She started her career at General Motors and Delphi where she was a First Line Manufacturing Supervisor for 5 years then became the EHS Manager for an 1800 person, union brake component shop. Ms. Whitehead holds a bachelor’s degree in Criminal Justice from the University

• f Cincinnati and is expected to receive her MBA from UC in August of 2017. Ms. Whitehead is also a

Certified Safety Professional.

Why do Smart People do Stupid Things?

Presented By: Richard Cutrell Michael Freeman Christina Whitehead “Safety People”

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Dystrationalia

Dysrationalia is defined as the inability to think and behave rationally despite adequate intelligence.

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“I know that I am intelligent because I know that I know nothing.”

• Socrates

“Common sense is not so common.”

• Voltaire

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Know versus Think

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What you KNOW versus what you THINK

A ball and a bat together cost $1.10 The bat costs a dollar more than the ball. How much does the ball cost?

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What you KNOW versus what you THINK

How do you properly pronounce the capital of Kentucky? A: “Louie – Ville” B: “Louis-ville” C: “Lou–uh-vull” D: ???

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Error versus Violation

Michael Freeman

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Definitions: Error and Violation

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Violation

– an action or inaction that intentionally departs from established work procedures

• r approved work practices

Error

– an action or inaction that unintentionally deviates from an expected work practice or procedure.

“A behavior which is totally under the control

• f the person: clear choices or procedures

were available and could have been executed, but the wrong decision was made

• r a short cut was taken.”
• - A Fortune 100 company

Error is NOT a Choice

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Old vs. New View of Human Error

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Human error is a cause of accidents To explain failure, investigations must seek failure We must find people’s inaccurate assessments, wrong decisions and bad judgments

Human error is a symptom of trouble deeper inside a system… To explain failure, do not try to find where people went wrong.

Instead, find how people’s assessments and actions made sense at the time.

Old View New View

Local Rationality People did things that made sense to them at the time; otherwise, they would not have done them (given their goals, mindset, and context).

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*Dekker, S (2006), The Field Guide to Understanding Human Error, p.12.

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Incidents don’t happen because people gamble and lose…

Keep in Mind

Incidents happen because the person believes that what is about to happen is not possible… what is about to happen has no connection to what they are doing… that the possibility of getting the intended

• utcome is well worth whatever risk there is.

OR OR

Reason’s “Swiss Cheese” Model of Human Error

Failed or Absent Defenses

Unsafe Supervision

Adapted from Reason (1990

Incident

Adapted from Error Management Solutions, LLC 2005

Human Fallibility 3-4 errors/ hour

Unsafe Acts seen as more a consequence of failed or absent defenses

Unsafe Acts

Preconditions for Unsafe Acts

Organizational Factors

Origin

Accumulation

Drift + Accumulation

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Danger Hi Time

Drift

Expectations “Normal” Practice

Margin for Error

Hidden conditions

Expectations: Desired state of work performed Normal Practices: Work as actually performed (allowed by mgmt!)

Error Violation Error

• Work as “imagined” by leaders -

Safety/Quality Lo

Unclassified 15

Error without consequence is a good thing — it shows that our systems are error- tolerant and that they are working.

Unclassified 16

Limitations of Human Nature

Mistakes arise directly from the way the mind handles information, not through stupidity or carelessness. — Dr. Edward de Bono

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Error and the Brain The hmuan barin deos not need spfeciic ltteers to be in oedrr in a wrod to udernstnad the wrod. All the huamn bairn needs is the frist leettr and the lsat lteter to be in tritiaonadl oredr to raed the wrod in a stanence.

State the “Word”

Green Brown Black Blue Green Pink Blue Pink Brown Green Black Red Blue Red Black Brown Black Pink Green Red Brown Green Pink Blue

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State the “Color”

Black Brown Black Blue Green Pink Brown Pink Brown Green Blue Pink Blue Pink Blue Black Pink Red Brown Red Brown Green Green Red

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State the “Color”

Black Brown Black Blue Green Pink Brown Pink Brown Green Blue Pink Blue Pink Blue Black Pink Red Brown Red Brown Green Green Red

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Risk-Important Actions and Critical Steps

All Procedure Steps All Risk-Important Actions All Critical Steps Critical Steps:

actions that will trigger immediate, irreversible harm

Risk-Important Steps:

procedure steps or actions that expose products, services, or assets to the potential for or actual harm.

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Hazardous Attitudes

Pride: “Don’t insult my intelligence.” Heroic: “I’ll get it done, by hook or by crook.” Invulnerable: “That can’t happen to me.” Fatalistic: “What’s the use?” Bald Tire: “Gone 60K miles without a flat yet.” Summit Fever: “We’re almost done.” Pollyanna: “Nothing bad will happen.”

Trade-Offs

• 1. People routinely make a choice

between being efficient (productive) and being thorough (safe), since it is rarely possible to be both at the same time (see herons/egrets).

• 2. If demands for productivity are

high (time to do), thoroughness is reduced until productivity goals are met.

• 3. If demands for safety are high

(time to think), efficiency is reduced until the safety goals are met.

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What do you want at critical steps?

Christina White he a d

Types of Error

Physical, observable actions that change equipment, personnel system or facility state, resulting in immediate unwanted outcomes (harm)

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An actions, inaction or decision that creates an unwanted condition, unnoticed at the time, causing no immediate, apparent harm to the work, facility, or personnel

“Accidents waiting to happen”

• -Kim Vincente, professor, University of Toronto

Latent (Hidden) Errors Active Errors

Undetected organizational deficiencies in facilities, processes, or values that create job-site conditions that provoke error and/or degrade the integrity of defenses.

Latent System Weaknesses

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e! Latent Weaknesses Accumulate!

Your organization is not basically

• r inherently safe. People have to

create safety by putting tools and technologies to use while negotiating multiple system goals at all levels of your organization.

Your Organization and the Human Error

“People at work cannot simply follow a prepared plan or set of procedures, but must constantly take the situation into account and make the necessary adjustments.”

• -Erik Hollnagel

The ETTO Principle, 2009 (Efficiency-Thoroughness Trade-Off)

Adaptability

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“It is better to know things as they are than to believe things as they seem.”

• -Kenneth Boa

Whe n thing s g o tra g ic a lly wro ng …wha t c a n we le a rn?

 1. I

de ntifying the hazards pre se nt in o ur wo rk is the c ritic a l

b a se line tha t a llo ws us to e limina te ha za rds o r imple me nt stro ng de fe nse s. I f we do no t e xe c ute we ll he re , we le a ve wo rke rs to ma ke the b e st de c isio ns the y c a n witho ut tra ining o r g uida nc e .

 2. Co mmunic ating the ha za rds, de fe nse s, a nd ta lking with

wo rke rs a b o ut why the y a re impo rta nt is the ne xt ste p.

 3. T

hink abo ut drift – a re the re c irc umsta nc e s whe re it mig ht

ma ke se nse to wo rke rs to no t fo llo w e sta b lishe d pro c e dure s? T a lk with wo rke rs a b o ut this, a nd use the insig hts to a ddre ss the se type s o f c irc umsta nc e s in yo ur tra ining a nd pla nning .

Whe n thing s g o tra g ic a lly wro ng …wha t c a n we le a rn?

 4. H

e lp wo rke rs unde rsta nd ho w to re c o g nize whe n the c o nditio ns o f wo rk

ha ve c ha ng e d e no ug h to trig g e r the E XPE CT AT I ON tha t the y must ST OP a nd RE ASSE SS b e c a use no rma l pro c e dure s a nd de fe nse s no lo ng e r a pply.

 F

• r e xa mple – a wo rke r in a c o nfine d spa c e is typic a lly no t a no rma l

wo rk ro utine , ye t whe n tha t wo rke r g o e s do wn, the wo rke rs o utside o f the c o nfine d spa c e will re a c t a nd g o in to try a nd sa ve the m witho ut e ve n thinking a b o ut it.

 Ho w do we c o mmunic a te to wo rke rs in a dva nc e , a nd ro utine ly, ho w

c ritic a l it is fo r the m no t to re a c t in the e mo tio n o f the mo me nt? We ne e d the m to unde rsta nd the y ha ve to sto p a nd re a sse ss ho w the y c a n sa fe ly try to he lp b y fo llo wing the e me rg e nc y pro c e dure s tha t we re put in pla c e in a dva nc e .

 5. Whe n we ta lk with wo rke rs re mind the m tha t no thing is mo re impo rta nt

tha n se nding the m ho me sa fe ly a t the e nd o f the da y, a nd a sk the m ho w we c a n a c c o mplish tha t.

 One a c c ide nt is b a d e no ug h, b ut whe n the sa me a c c ide nts ha ppe n o ve r a nd o ve r,

a nd whe n the sa me individua ls a re invo lve d in a c c ide nts mo nth a fte r mo nth, ye a r a fte r ye a r, so me thing ha s g o t to b e do ne to b re a k the vic io us--a nd po te ntia lly de a dly-

• c yc le .

 Sa fe ty e xpe rts b e lie ve tha t a b o ut 20 pe rc e nt o f wo rke rs c a use 80 pe rc e nt o f

a c c ide nts. So is it po ssib le tha t so me individua ls truly a re “a c c ide nt pro ne .” Who a re the se pe o ple ? T he y a re the o ne s who e xhib it the fo llo wing tra its:

 Sto ic “to ug h g uys,” who wo rk thro ug h a ny injury o r illne ss a nd c o nside r it a sig n o f

we a kne ss to do o the rwise ;

 Risk ta ke rs, who think a c c ide nts ha ppe n to o the r pe o ple ;  Ang ry pe o ple , who le t e mo tio ns distra c t the m fro m the ir wo rk b e c a use , a s the o ld

sa ying g o e s, the y a re “so a ng ry the y c a n’ t se e stra ig ht”;

 Shy wo rke rs, who do n’ t wa nt to dra w a tte ntio n to the mse lve s b y re po rting a n inc ide nt

• r ne a r miss;

 T

ire d pe o ple , inc luding shift wo rke rs, who se life style s do n’ t g ive the m e no ug h e ne rg y

• r a le rtne ss to wo rk sa fe ly;

3 fa c to rs must b e c o nside re d if we wa nt to b re a k the vic io us c yc le o f re pe a ta b le a c c ide nts:



Huma n fa c tors inc lude a n e mplo ye e ’ s:



L a c k o f jo b skills a nd kno wle dg e



Unsa fe wo rk style / ha b its (rushing , c a re le ss, ina tte ntive )



Po o r judg me nt (ta king sho rtc uts, skipping ste ps, no t b o the ring with pe rso na l pro te c tive e q uipme nt (PPE )



L a c k o f physic a l fitne ss (o ve rwe ig ht a nd o ut o f sha pe )



Distra c ting pe rso na l pro b le ms



Jobsite fa c tors inc lude :



No t ha ving the rig ht e q uipme nt fo r the jo b o r e q uipme nt in po o r c o nditio n



Wo rke rs fitte d to jo b s ra the r tha n jo b s fitte d to wo rke rs



I mpro pe rly la id o ut wo rk spa c e s tha t do n’ t pro vide e a se o f mo ve me nt a nd wo rke r c o mfo rt



I na de q ua te ly ma na g e d wo rk flo w re sulting in wo rklo a d spike s a nd o ve rlo a ds



Po o rly lit, lo ud, o ve r- o r unde rhe a te d wo rk e nviro nme nts



Sa fe ty c ulture fa c to rs inc lude :



An e nviro nme nt in whic h sa fe ty a nd he a lth a re n’ t prio ritie s a nd sa fe b e ha vio ur isn’ t re info rc e d a nd re wa rde d



Ac c ide nt inve stig a tio ns tha t do n’ t g e t to the ro o t c a use s o f a c c ide nts a nd fa il to c o rre c t sa fe ty pro b le ms to pre ve nt future a c c ide nts

L e a rning from our Mista ke s

We a re g e ne ra lly g uilty o f 3 thing s whe n de a ling with mista ke s:



• 1. We Ra tiona lize



Ra tio na liza tio n is the pro c e ss o f c o ming up with a ppa re ntly se nsib le e xpla na tio ns fo r o ur b e ha vio r. T his line o f re a so ning c o me s to us na tura lly b e c a use we do n’ t wa nt to fe e l b a d o r g uilty so inste a d, we g e t de fe nsive a nd g ra sp fo r a ny po ssib le re a so n fo r o ur a c tio ns tha t g e ts us o ff the ho o k.



• 2. We Convinc e Ourse lve s It Wa s Simply a F

luke



Ofte n whe n we ma ke a mista ke we c o nvinc e o urse lve s it wa s a n a b e rra tio n, a o ne -time e ve nt tha t ha ppe ne d b e c a use o f b a d luc k, the sta rs a lig ne d a g a inst us, o r wha te ve r. But the b o tto m line is we c ho o se to put the e xpe rie nc e b e hind us a nd mo ve o n a s q uic kly a s po ssib le witho ut trying to le a rn a nything a b o ut the dyna mic s o f the mista ke b e c a use we a ssume it will ne ve r ha ppe n a g a in.



So me time s mista ke s ha ppe n e ve n whe n we ma ke a ll the rig ht c ho ic e s, b ut o the r time s the y a re a sig na l tha t o ur inte rna l se lf is trying to te ll us the re is so me thing fa r mo re se rio us g o ing o n. T he o nly wa y to g e t o ff the me rry-g o - ro und is to ta ke the time to unde rsta nd a nd le a rn fro m o ur c ho ic e s a nd b e ha vio rs.



• 3. We Don’t T

a ke T ime to Unde rsta nd Wha t We nt Wrong



So me time s we re c o g nize a nd ta ke re spo nsib ility fo r the mista ke , b ut ne ve r b o the r to unde rsta nd why it ha ppe ne d. Mista ke s a re a re a lity c he c k. T a king re spo nsib ility fo r the c o nse q ue nc e s o f o ur mista ke s is just the first ste p, b ut it puts us in a b e tte r po sitio n to do the wo rk to unde rsta nd wha t’ s wo rking –a nd wha t isn’ t. I f we c ho o se to de ny o r mo ve o n fo r the sa ke o f putting the e ve nt b e hind us we miss o ut o n a po we rful o ppo rtunity to le a rn a b o ut o ur b e ha vio rs, the thing s we sa y, do a nd think, pa rtic ula rly if it’ s a re c urring pa tte rn.

T he Risk o f Co mpla c e nc y

Just when you thought it was safe to go back to work…

“Every time someone asks me, ‘Do you really think someone would actually do that?’, I remind them that there is a guard rail at the top of the Grand Canyon.”

• Richard Cutrell ( aka ‘Safety Boy’ )

• Drove a raised trailer into the Low Bridge… (Twice)
• Ran an entire batch with the drain valve open
• Opened top hatch on an actively running reactor to look inside
• Placed a chemical jar next to their foot and then kicked it over
• Drove through doorways with forks all the way up.. Twice
• Placed parts of ourselves into actively running machines
• Closed doors on the forklift as they drove through door
• Stabbed ourselves
• Placed hand inside machine and then instructed partner to cycle

the machine

• People are human and humans make

mistakes and misjudge situations.

• We can reduce mistakes through

training and consistently demonstrating safe behavior

• Create the path of least resistance

• Incident Reports:
• Injuries
• Spills
• Near Misses
• Damage/Crashes
• All incidents are investigated so that we can better understand

how and why they occurred and therefore initiate corrective actions to correct the unsafe conditions.

• Guarding / Light Curtains
• Automatic Equipment
• 3D Powerwash
• Guard Rails
• Air Movers / Exhaust

• Good work practices are expected and part of

the culture so that workers wouldn't think of doing something the wrong way.

• This is how hardhats and seat belts became a

way of life - people should speak up when unsafe work occurs and not let it slide.

• Very Difficult to change traditions.

• Many people think safety will slow the job

down, but companies that make safety a priority with better planning and integrated safety leads to higher job satisfaction, higher quality, higher efficiency, and a longer tenure for employees.

• New employees are educated and trained
• n the job and learn the most through the

example of the experienced work force.

• If the experience people cut corners, the

inexperienced people will follow right along.

Why?

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Questions and Comments

Presented By: Richard Cutrell Michael Freeman Christina Whitehead

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