Categorising Human Failures - PowerPoint Presentation

1. Categorising Human Failures Fair and just

2. What is a “Fair and Just Culture”The concept of “Fair and Just Culture”, is about using a consistent approach and interpretation of the facts relating to an incident investigation.Using objective analysis rather than an subjective opinion to establish the root cause of any human error.To ensure the correct actions are taken to prevent reoccurrence of the eventCare: first priority, second nature

3. HazardsIncidentOrganisationalcontrolsLeadership /SupervisionTools andEquipmentSafebehaviourAn individual person becomes the last barrier between the hazard and a situation where all barriers are lined up

4. Holes in this last barrier are caused by human failuresWhat factors contribute to these human failures ??

5. Addressing unsafe behaviourRe-designworkplace/practisesRe-educateworkforceReinforceleadership

6. Fair and Just Decision TreeCare: first priority, second nature

7. HazardsIncidentBlameless error.Blameless error.Training, counseling, consider suitability for job.System induced error.Possible negligent error, e.g. slip, lapse or mistake.System induced violation.Possible reckless violation.Sabotage, malevolent damage, suicide, etc.Individual actions?Drugs and alcohol test positive?Follow Drugs and Alcohol PolicyWere the actions intended?Were the consequences intended?(Potential or actual injury or plant and/or equipment damage)Knowingly violatedsafe operating procedures? Procedures available, intelligible and well communicated?Employee trained and audited?Substitution test: Would another employee with same training and experience have done the same?Deficiencies in training, selection and or experience?History of unsafe acts?YESYESYESYESYESYESYESYESNONOYESNONONONOApply disciplinary policyIdentify SYSTEM failuresNONO

8. HazardsIncidentBlameless error.Blameless error.Training, counselling, consider suitability for job.System induced error.Possible negligent error, e.g. slip, lapse or mistake.System induced violation.Possible reckless violation.Sabotage, malevolent damage, suicide, etc.Individual actions?Drugs and alcohol test positive?Follow Drugs and Alcohol PolicyWere the actions intended?Were the consequences intended?(Potential or actual injury or plant and/or equipment damage)Knowingly violatedsafe operating procedures? Procedures available, intelligible and well communicated?Employee trained and audited?Substitution test: Would another employee with same training and experience have done the same?Deficiencies in training, selection and or experience?History of unsafe acts?YESYESYESYESYESYESYESYESNONOYESNONONONOApply disciplinary policyIdentify SYSTEM failuresNONOThis person deliberately caused the outcome

9. HazardsIncidentBlameless error.Blameless error.Training, counselling, consider suitability for job.System induced error.Possible negligent error, e.g. slip, lapse or mistake.System induced violation.Possible reckless violation.Sabotage, malevolent damage, suicide, etc.Individual actions?Drugs and alcohol test positive?Follow Drugs and Alcohol PolicyWere the actions intended?Were the consequences intended?(Potential or actual injury or plant and/or equipment damage)Knowingly violatedsafe operating procedures? Procedures available, intelligible and well communicated?Employee trained and audited?Substitution test: Would another employee with same training and experience have done the same?Deficiencies in training, selection and or experience?History of unsafe acts?YESYESYESYESYESYESYESYESNONOYESNONONONOApply disciplinary policyIdentify SYSTEM failuresNONODespite all audited efforts, this individual still did what they should not have done

10. HazardsIncidentBlameless error.Blameless error.Training, counselling, consider suitability for job.System induced error.Possible negligent error, e.g. slip, lapse or mistake.System induced violation.Possible reckless violation.Sabotage, malevolent damage, suicide, etc.Individual actions?Drugs and alcohol test positive?Follow Drugs and Alcohol PolicyWere the actions intended?Were the consequences intended?(Potential or actual injury or plant and/or equipment damage)Knowingly violatedsafe operating procedures? Procedures available, intelligible and well communicated?Employee trained and audited?Substitution test: Would another employee with same training and experience have done the same?Deficiencies in training, selection and or experience?History of unsafe acts?YESYESYESYESYESYESYESYESNONOYESNONONONOApply disciplinary policyIdentify SYSTEM failuresNONONot all barriers were in place, the systems that protected people were not effective

11. HazardsIncidentBlameless error.Blameless error.Training, counselling, consider suitability for job.System induced error.Possible negligent error, e.g. slip, lapse or mistake.System induced violation.Possible reckless violation.Sabotage, malevolent damage, suicide, etc.Individual actions?Drugs and alcohol test positive?Follow Drugs and Alcohol PolicyWere the actions intended?Were the consequences intended?(Potential or actual injury or plant and/or equipment damage)Knowingly violatedsafe operating procedures? Procedures available, intelligible and well communicated?Employee trained and audited?Substitution test: Would another employee with same training and experience have done the same?Deficiencies in training, selection and or experience?History of unsafe acts?YESYESYESYESYESYESYESYESNONOYESNONONONOApply disciplinary policyIdentify SYSTEM failuresNONOThere was no intent, but others would not have behaved this way, and despite training and being suitable for the job this undesirable behaviour still happened

12. HazardsIncidentBlameless error.Blameless error.Training, counselling, consider suitability for job.System induced error.Possible negligent error, e.g. slip, lapse or mistake.System induced violation.Possible reckless violation.Sabotage, malevolent damage, suicide, etc.Individual actions?Drugs and alcohol test positive?Follow Drugs and Alcohol PolicyWere the actions intended?Were the consequences intended?(Potential or actual injury or plant and/or equipment damage)Knowingly violatedsafe operating procedures? Procedures available, intelligible and well communicated?Employee trained and audited?Substitution test: Would another employee with same training and experience have done the same?Deficiencies in training, selection and or experience?History of unsafe acts?YESYESYESYESYESYESYESYESNONOYESNONONONOApply disciplinary policyIdentify SYSTEM failuresNONOThere was no intent, but others would not have behaved this way, however part of this is because training and selection were not adequate

13. HazardsIncidentBlameless error.Blameless error.Training, counselling, consider suitability for job.System induced error.Possible negligent error, e.g. slip, lapse or mistake.System induced violation.Possible reckless violation.Sabotage, malevolent damage, suicide, etc.Individual actions?Drugs and alcohol test positive?Follow Drugs and Alcohol PolicyWere the actions intended?Were the consequences intended?(Potential or actual injury or plant and/or equipment damage)Knowingly violatedsafe operating procedures? Procedures available, intelligible and well communicated?Employee trained and audited?Substitution test: Would another employee with same training and experience have done the same?Deficiencies in training, selection and or experience?History of unsafe acts?YESYESYESYESYESYESYESYESNONOYESNONONONOApply disciplinary policyIdentify SYSTEM failuresNONOEverybody does it like this because of custom and practice or because we train it like this, but this person has done this kind of thing before so they need to be talked to

14. HazardsIncidentBlameless error.Blameless error.Training, counselling, consider suitability for job.System induced error.Possible negligent error, e.g. slip, lapse or mistake.System induced violation.Possible reckless violation.Sabotage, malevolent damage, suicide, etc.Individual actions?Drugs and alcohol test positive?Follow Drugs and Alcohol PolicyWere the actions intended?Were the consequences intended?(Potential or actual injury or plant and/or equipment damage)Knowingly violatedsafe operating procedures? Procedures available, intelligible and well communicated?Employee trained and audited?Substitution test: Would another employee with same training and experience have done the same?Deficiencies in training, selection and or experience?History of unsafe acts?YESYESYESYESYESYESYESYESNONOYESNONONONOApply disciplinary policyIdentify SYSTEM failuresNONOThis person does follow all the rules and standards, and is in line with other colleagues, but unfortunately sometimes unexpected things happen