Foresight Training. Error Wisdom on the frontline

Transcription

1 Foresight Training Error Wisdom on the frontline

2 Human Factors in Safety People Task Organisation

3 Performance Influencing Factors (PIF s) Performance Influencing Factors (PIFs) are the characteristics of the job, the individual and the organisation that influence human performance. Some examples are given below. Task: Clarity of signs, instructions Error tolerance Difficulty/complexity of task Routine or unusual Divided attention Procedures inadequate or inappropriate Preparation for task Time available/required Tools appropriate for task Communication, with others Individual: Physical capability and condition Fatigue Stress/morale Work overload/underload Competence to deal with circumstances Motivation vs. other priorities Organisation: Work pressures Quality of leadership Communication Manning levels Peer pressure Clarity of roles and responsibilities Consequences of failure to follow rules/procedures Effectiveness of organisational learning Organisational or safety culture

4 Background and introduction to foresight training Foresight is the ability to identify, respond to, and recover from the initial indications that a safety incident could take place. It involves frontline staff recognising the potential safety risks in the work system, and considering intervening to prevent an incident. Foresight skills include intuition, wariness, vigilance

5 An example of foresight Walking home at night constant awareness, ever watchful for danger, feral vigilance, safety is second nature

6 Examples of foresight training Non-technical skills training in aviation Western Mining Corporation. Take time, take charge (Hopkins) Metropolitan Police: hazard awareness training ESSO s step back by five programme BP s integrity management training NHS (UK) foresight training for nurses

7 Rationale Reason (2004) states that people at work can detect, assess and avoid potentially dangerous situations by evaluating three aspects for the job they are doing: how safely they are working; the context in which they are working; the task being carried out. Evaluation of the three aspects provides a measure of when to make alarm bells ring for staff confronted with a potentially unsafe situation.

8 Factors within the work system that could potentially cause harm The system Environment Workspace Task Equipment People Managers work on the system, staff work in the system Frontline Staff Working Interface Staff act as harm absorbers

9 Concept of foresight training Error wisdom on the frontline James Reason 2004

10 The three bucket model for assessing risky situations (Reason, 2004)

11 Assessing the Risk Serious risk: If feasible don t go there Moderate to serious: be very wary Routine to moderate: proceed with caution

12 Self Bucket Level of knowledge Level of skill Level of experience Current capacity to do the task newly qualified competence and experience auto-pilot, under/over confidence fatigue, time of day, negative life events

13 Context Bucket Equipment and devices Physical environment Workspace Team and support Organisation and management usability, not available lighting, noise, temperature working environment, writing space, leadership, stability and familiarity, trust safety culture, culture, targets and workload

14 Task Bucket Errors Task complexity Novel task Process omission errors, primary goal achieved before all steps complete, lack of cues from previous steps calculations unfamiliar or rare events task overlap, multi-tasking

15 Interactive Workshop 1. Read the scenario/watch the video 2. Think about the unfolding scenario 3. Review in terms of the three bucket model

16 Read the scenario or watch the video

17 What is in the buckets? Work in small groups Discuss what was in the Self, Context and Task buckets Write one factor down on each Post-It note 20 minutes to discuss as a group 15 minutes group feedback

18 Role of the Supervisor in Applying Foresight Training Supervisors required to ask, in their daily interactions with their direct reports, for specific examples of three bucket risk assessments Supervisors collate and report those examples to a central administrator Managers ask supervisors in their regular meeting for the examples they have obtained from the frontline staff Administrator summarise and analyse risk assessments Metrics created to monitor level and content of these risk assessments Feedback of action to original reporters of examples judged to be significant

19 What are the benefits if foresight training? Facilitates learning about safety risks from more experienced staff. Improves frontline staff s ability to recognise and intervene at the first signs of a problem. Creates safety practice amongst supervisors and managers of asking for examples of problems Raises awareness of safety incidents, and in particular, near misses. This in turn could lead to improved near miss reporting rates and therefore important learning opportunities.