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Understanding Human Liability
Below is a high level outline of the fundamentals behind Human Liability training as a method for avoiding injuries, mistakes, and improving outcomes. This document is not intended to be comprehensive training program, but instead to offer a basic understanding of the theory behind Human Liability Systems. It is our belief that every organization can benefit from some or all of the systems outlined in this document.
Everyone is fallible. The most successful organization understand:
- Individual behavior is influenced by organizational processes and values;
- Error likely situations are predictable, manageable, and preventable;
- Events can be avoided by understanding the reasons mistakes occurred and applying lessons learned from past events;
- People achieve their highest levels of performance based on positive recognition and reinforcement;
- Leadership must equally value production and people.
- Training is a necessary part of the system, but won't fix problems by itself.
- Sustainable improvement in human error management is not dependent solely on workers.
Human liability can occur in a variety of ways. It can range from an accounting mistake that results in a small monetary loss, to a serious workplace accident that results in a life altering injury. Outcomes can be improved in all aspects of the workplace by understanding human liability traps and instituting appropriate defenses.
STRATEGIES FOR AVOIDING HUMAN LIABILITY AND IMPROVING OUTCOMES.
Recognize Human Error Traps
The first step to understanding human liability and improving outcomes is to identify traps. The following are common traps that directly lead to mistakes, injury or near-miss outcomes. These apply equally to every industry whether it is a manufacturing, healthcare, construction, or office settings.
- Production pressure.
- Distractions and interruptions.
- Multiple tasks.
- Bias for results (over confidence). Thoughtless.
- Vague or interpretive guidance.
- First time performing task/infrequently performed.
- Change of duty/off normal.
- Physical environment.
Understand Human Relations Fundamentals
The next step is to institute controls that will include and engage employees in ongoing safety protocols. Each employee must be empowered to engage in their own safety.
- Know when to stop.
- Questioning attitude. Why am I doing this?
- Place keeping - force to read through policy, and check sections when read.
- Effective communication - If an employee is given instructions, the person receiving instruction reads or recites them back.
- Job site review - policy/practices - snapshot of jobsite. The employee engages in this practice every shift prior to starting work. What are the risks present? Can a solution be engineered to mitigate?
- Meeting attendance. Employees must be engaged in their own wellbeing.
These fundamentals are not limited to safety and apply equally to security and quality functions in an office or corporate environment.
Understanding Human Reliability Defenses
These are practices and policies any company can engage in to create a defense against loss.
- Verification Practices - Peer checking. If an employee is unsure, he or she has someone to ask, "am I doing this correctly?"
- Procedure use and compliance. Policies and procedures must be up to date and employees must know to use them.
- Coaching (peer to peer) - observation program with workers comfortable coaching each other. Hierarchy shouldn't matter for effective for effective peer coaching.
- Pre-Job Brief - Here is what we want to accomplish during this shift, or for this project, here is what we want to avoid - provide opportunity for feedback.
- Turnover - Make sure people handing projects off communicate.
- Walkdowns - This is a pre-job inspection - In the manufacturing setting allow employees to review the or task project before the start of their shift or the task for barriers and problems (e.g. insufficient overhead light, missing safety barrier, obstacles preventing safe completion of task, missing element needed). In other settings, before starting a project or shift, each employee should complete a pre-job inventory to identify barriers for successful completion.
- Robust Barrier - Anything preventing interface with equipment employee will work on - post-its, alarms, reminders.
Developing Effective Trending
Trending is the theory that we can predict errors by trending low level mistakes that didn't have big consequences. The near misses are the mistakes that were caught before they resulted in a loss, or the injury that almost happened. These are the "we got lucky" scenarios. These offer incredible insight into areas of exposure for any company. Each near miss is an opportunity to proactively evaluate high risk areas of liability.
- Human error reviews can pinpoint error traps, missing individual fundamentals, and defenses before errors or incidents occur.
- Effective trending needs to get inside the head of your personnel to understand what the involved personnel were thinking when the error occurred. The purpose is not blame. It is to better understand the environment in which errors occur so that they can be eliminated in the future.
- Observation Program - Watch people to see where errors or most likely to occur. Pay attention to the culture in the department. Every department has a subculture defined as the way staff and managers interact, sometimes this culture is the source of errors.
- Identify retraining and process improvements such as procedure quality and labeling.
Coaching is the practice of conducting observations and comparing behaviors to existing standards and expectations.
Remember, individual behavior is influenced by leadership values. Workers will value what owners and managers value.
The most effective managers coach regularly rather than waiting for yearly reviews.
Coaching Opportunities: Each of these areas represents an opportunity for coaching.
- Infrequent evolution.
- High risk tasks.
- Work performed by contractors.
- Pre-job brief (observe them).
- Component manipulations.
- Morning meeting.
- Leadership meetings.
- Peer to peer coaching adds value.
A successful observation program enables employees to assess procedure compliance and record safety observations, stop work that's unsafe. An effective observation program will minimize errors by 60%.
This isn't limited to safety. An observation program can also assess compliance in a number of functions, by recording noncompliance observations, this behavior can be stopped before it results in a loss.
The following are some best practices for any observation program:
- Make Behavior Based Observations - don't give statements like "performance declined," instead, give behavior based observations that identify particular behavior that can improve.
- Make Sure All Documentation is Closed Loop - Don't just document a problem. Identify the problem, and then identify how it was dealt with. This adds value because if the problem reoccurs, it is an opportunity to examine whether a different method of dealing with a problem is appropriate.
- Make Sure Observations Are Aligned with the Performance Challenge - Stay focused on the performance being measured and offer relevant observations.
- Allow for Feedback - Allow an opportunity for feedback between the observations and outcomes.
- Not Disciplinary - Employees have to be comfortable to make reports in order for a near miss observation program to be successful. It is not as effective if it becomes a disciplinary model, instead it should be a form of coaching for improvement rather than coaching for discipline.
An effective human liability assessment will present an organization with an opportunity to correct a problem before it becomes a consequential incident. Near miss reporting of "we got lucky" scenarios represent an opportunity for growth. Coaching and observation allow employees and management to recognize and proactively manage risk.
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