TheMisfortuneMurphyModel•Willhelpusunderstandhowhumanerrorsresultinaccidents•Willassistusinunderstandingtherootcausestoanaccident•WillillustratetheroleofSafetyManagementSystems(SMS)inpreventingaccidents•WillhelpusunderstandwhatWEcandotohelppreventfutureaccidentsLatentConditionsManagementDecisions•ManagementDecisionssetup“LatentConditions”LatentConditionsAsystemcondition(policy,decisionor“norm”)thatlaysdormantuntilanactivefailurenormallybringsittolightTheyaretherebutoftennotrecognizedasdangerousuntiltoolateManagementDecisions•Setthe“scene”fortheActiveFailuretooccur•Seemlikegoodideasatthetime•Maylaydormantforalongtime•Whenalltheconditionsare“wrong”anaccidentoccursifthereisnoSafetyNettostopit.•TheSafetyNetmaybepresenthoweverithasaholeinit(notbeingfollowed)•ManagementDecisionssetup“LatentConditions”LatentConditionsLatentConditionsLineManagementDecisions•LineManagementDecisions“LatentConditions”•Aredecisionsmadebasedonwhattheythinkthemanagementreallywants•Aretherebutarenotrecognizedaspotentiallydangerous•Mayalsolaydormantforalongtime•Whenalltheconditionsare“wrong”anaccidentoccursifthereisnoSafetyNettostopit•TheSafetyNetmaybepresenthoweverithasaholeinit(notbeingfollowed)LatentConditionsLatentConditionsLatentConditionsPreconditions-TheDirtyDozen1.LackofCommunication2.Complacency3.LackofKnowledge4.Distraction5.LackofTeamwork6.Fatigue7.LackofResources8.Pressure9.LackofAssertiveness10.Stress11.LackofAwareness12.NormsPreconditionsToaHumanError•Setthepersonuptomaketheactiveerror•AreoftenacombinationofmorethanoneoftheDirtyDozenLatentConditionsLatentConditionsLatentConditionsActiveFailuresTheActiveFailureThe“guiltyparty”whomakesthemistakethatresultsinahumanerrorItwillbeanactionorlackofactionthatresultsintheerrorItistheRESULTbutNOTtheCAUSE•Isusuallyveryexperienced•Hasnointentionofmakingtheerror(Heknowsbetter)•Oftenhasnoideahowhecouldhavebeenso“careless”•Willoftenpunishhimselfmorethanthesystemcan•IsveryunlikelytoeverdoitagainActiveFailuresAreUsuallyProductiveActivitiesThatInvolveanUnsafeActTheGuiltyPartyThe“GuiltyParty”LatentConditionsLatentConditionsLatentConditionsActiveFailuresActive&LatentFailuresSafetyNets•Lastchancetopreventtheaccidentfromoccurring•IfthereisnoSafetynetinplacethenitisaLatentFailure•TheSafetyNetmaybepresenthoweverithasaholeinit(notbeingfollowed)•IftheSafetynetisnotbeinguseditisanActiveFailureHowmanytimesdoesthechainofeventsgetallthewaytotheSafetynetandisstoppedthere?SMSIncidentDripTrayLatentConditionsLatentConditionsLatentConditionsActiveFailuresActive&LatentFailuresTheSMSIncidentDripTray•Servestocatchthe“nearmisses”thatcouldhavecontinuedontocauseanaccident•Requiressomeoneto“fessup”andreportthe“nearmiss”•Requiresasystemtotakeandanalyze(riskassess)thedatainthe“driptray”•Thesystemwillthenusethisinformationto“plugorreducethesizeofsomeoftheholes”thatallowthechainofeventstooccur•Thisresultsinfeweraccidents•Welearnfromanaccidentwedidn’thaveSMSIncidentDripTray80-90%10-20%LatentConditionsLatentConditionsLatentConditionsActiveFailuresActive&LatentFailuresFreeLessonTrayYOUAretheKeytoSafety•YOUarethepersonwhohasthe“nearmisses”•YOUaretheonewhocanputinformationintothe“IncidentDripTray”•YOUcanprovidetheinformationthatwillhelp“plugtheholes”•YOUcanprovidethe“FreeLessons”thatenabletheorganizationtolearnwithouthavingtohaveanaccident•SMSwillrequireYOURinputtowork
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