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.”
Workers look for familiar patterns and apply well-tried solutions to a problem. There is the temptation to settle for satisfactory solutions rather than continue seeking a better solutions. The mental biases, or shortcuts, often used to reduce mental effort and expedite decision-making include:
It has taken me 25 years to diagnose it, but I have finally establish the “Delusional Safety Syndrome” (DSS). It is the only mental illness known at this time that is actually contagious. It is spread by close contact with an infected person. It can lie dormant for years and the infected person can spread
As part of their Industrial Safety Ordinance Contra Costa County, CA developed a VERY NICE safety culture survey. It is a requirement for CalARP facilities, but just a GREAT RESOURCE for the rest of us. Check it out Attachment E: Safety Culture Assessment (PDF). You may have some work to do to get it in
The “Swiss-Cheese” Model, developed by Professor James Reason, illustrates that accidents involve successive breaches of multiple system defenses. These breaches can be triggered by a number of enabling factors such as equipment failures or operational errors. Since the Swiss-Cheese Model contends that complex systems are extremely well defended by layers of defenses, single-point failures are
A wholly just culture is almost certainly an unattainable ideal. However, an organization in which most of its members believe that justice will usually be dispensed is within the bounds of possibility. Two (2) things are clear at the outset. First, it would be quite unacceptable to punish all errors and unsafe acts regardless of
As Asiana Airlines Flight 214 flew into San Francisco International Airport on Sunday July 7, the Boeing 777’s 291 passengers didn’t know that the man at the controls had never landed this kind of plane at this airport before. Does it matter that the pilot at the time – aviation veteran Lee Kang-kuk – has only
A little boy went into a drug store, grabbed a stool at the counter and pulled it over to the telephone. He climbed onto the stool so he could reach the buttons on the phone and proceeded to dial someone. The store-owner observed and listened to the conversation. Boy: ‘Lady, Can you give me the
Unsafe acts are of two (2) distinct types: errors and violations Errors arise from informational problems and fall into three (3) categories: skill-based slips and lapses, rule-based mistakes and knowledge-based mistakes Violations arise from motivational factors and fall into four types: routine (or corner-cutting) violations, thrill-seeking or optimizing violations, necessary violations and exceptional violations Everyone
Risk assessment is the process where you: Identify Hazards Analyze Hazardsor Assess the risk that hazard poses to people, equipment, business Determine appropriate ways to eliminate or control the hazard
A highly reliable (resilient) organization is a LEARNING ORGANIZATION. Learning organizations exhibit five (5) main characteristics: system thinking, personal mastery, mental models, a shared vision, and team learning
Reason (1997) has identified a number of characteristics that go to make up such a safety culture. These are:
