PETROLEUM SAFETY CONFERENCE

Transcription

1 PETROLEUM SAFETY CONFERENCE MIKE SEDAM

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17 Risks ROLES and Relationships Human Behaviour in Safety MIKE SEDAM

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19 and Risks ROLES Relationships Things to Consider: We all play multiple roles Roles help us make sense of the world Behaviors assigned to roles affect our decisions

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28 Risks Hazard Risk Risk Tolerance

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30 ROLES

31 Man is by nature a social animal. Society is something that precedes the individual. Aristotle, Politics

32 Worker Executive Manager Supervisor Customers/ Receivers Administration Regulators/ Lawmakers

33 Relationships

34 and Risks ROLES Relationships Whole organization needed Productive or destructive Social motivators are stronger than money motivators

35 and Risks ROLES Relationships

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40 September 19, 1980

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43 19 Year Old New Guy I was ready to take on the world.

44 19 Year Old New Guy I was ready to take on the world.

45 21 Year Old Experienced Technician be the best PTS Chief ever.

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47 Risks

48 Risks

49 Risks Do we see the risk? If you don t see it, you take risk Do we understand the risk? If you don t understand it, you take risk Do we accept the risk? If you see it and understand it, do you accept it? Do we accept any risk?

50 Risks What are some of the ways our tolerance of risk is impacted? We re good at it. We do it a lot. We know how to use these tools. Our protective equipment is good. It s how he does/it s how I was taught. Role models/prototypes.

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55 and Risks ROLES Relationships Powell (Experienced Technician) Plumb (New Guy) Strategic Air Command Missile Alert Crew

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58 I radioed that we had a milky white cloud In case the commander was listening, I didn t want him freaking out. - Dave Powell, PTS A

59 I guess it would be like you doing something wrong as a kid You don t want to say what you just did. - Jeffrey Plumb, PTS A

60 Team Errors 14% fail to recognize 74% fail to notify 12% fail to correct Why? Embarrassment Do not want to get in trouble Burdensome process

61 We saw the pressure was dropping fast. Then all of a sudden sprays came on in the launch duct. It doesn t make any sense. Nothing made any sense. And I jumped into my checklists.

62 Checklists: 1. Fuel leak 2. Oxidizer leak 3. Fire

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65 Commander of the 308 th Missile Wing in Little Rock I had no previous experience in Titan.

66 I knew a socket had been dropped. I had heard that tools have been dropped before. But they had always dropped straight to the bottom. I had no idea that could ever happen.

67 1 Heinrich

68 Fatality Serious Injury Minor Injury Near Miss Unsafe Acts

69 Fatal Serious 1 29 Minor Injury Near Miss Unsafe Acts 300

70 Social Exceptional Companies Can Do This Money Most Companies Can Do This

71 Strategic Air Command Learning from near misses? Open communication? Trust up-and-down the chain? Trust horizontal between teams? Trust within the team (e.g. PTS Powell and Plumb) Trust external to the system? (What s your guess)

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74 Sheriff Frustrated with USAF in the past, knew everyone in town. Gus Anglin Sheriff

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76 Sheriff Frustrated with USAF in the past, knew everyone in town. Gus Anglin Sheriff Evacuate everyone within a mile of the missile.

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78 PTS Team Chief One of the best team chiefs in the wing Jeffrey Kennedy PTS Team B SAC has never stepped foot on a missile complex.

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80 Commander of the 308 th Missile Wing in Little Rock To err was human. To forgive wasn t SAC policy.

81 I can t afford to differentiate between the incompetent and the unfortunate. Curtis Lemay

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86 Us vs. Them I and They Human error was blamed Not the system Without these bad actors it never would have happened Did the system have a CAPACITY for SAFETY? Should a dropped socket result in a nuclear warhead being found in a ditch?

87 Key Takeaway 1 Trust is the key If we are focused on threats within, we can t focus on outside threats

88 Key Takeaway 2 Risk Tolerance How would the prototype do it? Remember how it is supposed to be done Your equipment may fail Remember this time may not be like last time How would you teach a rookie to do it?

89 Key Takeaway 3 The roles we play are important Impact our decisions Impact our emotions and morale Impact our relationships

90 Key Takeaway 4 Perception of the situation affects how we will respond. SAC was making the calls, but the experts on the ground needed to be making decisions Use an appropriate framework Is it simple? Is it complicated? Is it complex? Is it chaos?

91 Key Takeaway 5 Relationships make us stronger Required: psychology, biology, anthropology Impacts sense-making and decision-making Trust is essential Stronger relationships reduce burnout The stories we tell are more powerful than policy.

92 Key Takeaway 6 Stories are more powerful than policy How it works here What you learn in a book vs. experiences What you feel Like a simulator for a pilot

93 Wrap Up 1. All levels see and understand risk 2. Effective and resilient systems 3. Expectations and standards are managed at the front line (nozzle of the fire hose/pointy end of the spear) 4. Organization provides support and feedback loops (learning)

94 Wrap Up 1. Contact me at any time 2. Free resources: 3. Free podcast: Crucial Talks Podcast 4. LinkedIn (Mike Sedam), Twitter Facebook (Crucial Talks Page) Mike Sedam

95 and Risks ROLES Relationships Workshop after lunch Conversation about how to handle simple, complicated, complex, and chaotic events.

96 and Risks ROLES Relationships Simple Easy, stable, clear cause-and-effect Complicated Multiple right answers Complex Difficult to find the answer (multiple unknowns), constantly moving and changing Chaotic Pointless to search for the answer Cause-and-effect are impossible to figure out For More Information: The Cynefin Framework

97 and Risks ROLES Relationships Simple

98 and Risks ROLES Relationships Simple Sense Categorize Respond

99 and Risks ROLES Relationships Complicated

100 and Risks ROLES Relationships Complicated Sense Analyze Respond

101 and Risks ROLES Relationships Complex

102 and Risks ROLES Relationships Complex Probe Fail Safely Sense Respond

103 and Risks ROLES Relationships Chaotic

104 and Risks ROLES Relationships Chaotic Act Sense Respond

105 Rule-Based Skill-Based Simple Complicated Complex Chaotic Knowledge-Based

106 Wrap Up 1. Contact me at any time 2. Free resources: 3. Free podcast: Crucial Talks Podcast 4. LinkedIn (Mike Sedam), Twitter Facebook (Crucial Talks Page) Mike Sedam