Part One Understanding human performance in complex...
Transcript of Part One Understanding human performance in complex...
![Page 1: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/1.jpg)
Understanding human performance in complex systems
Dik Gregory and Paul Shanahan
Part One
1
![Page 2: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/2.jpg)
2
![Page 3: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/3.jpg)
People trade off.
Efficiency Thoroughness?
How do people deal with limited resources?
3
![Page 4: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/4.jpg)
State
Understanding
Goals
sensessense-making
biasesemotionsknowledge
riskmeaning
experience
memorymoodfatigue stress
personalityhealth boredom
complacencyattitudes
purposes plans
expertise
motivation
procrastinationhabits willpower
valuesneeds skills
How do we decide what is ‘good enough’?
FairnessBelonging
Social contactAutonomy
Cooperation
4
![Page 5: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/5.jpg)
Review
State
Understanding
Goals
sensessense-makingbiases
emotionsknowledge
riskmeaning
moodfatigue stress
personalityhealth boredom
complacencyattitudes
purposes plansprocrastinationhabitswillpower
motivationvalues
AEfficiency Thoroughness
SUGAR
expertiseneeds
How do we decide what is ‘good enough’?
5
![Page 6: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/6.jpg)
Teamworking
Social pressure
Diversity
CultureLeadership
Social capitalTrust
LanguageHow do we synchronise our decisions with each other?
6
![Page 7: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/7.jpg)
What’s different about complexity?
Distributed control
Tight connection
Fundamental uncertainty
Necessary performance variability
Tendency for system ‘drift’
No need for complication!
7
![Page 8: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/8.jpg)
What’s different about complexity?
Distributed control
Tight connection
Fundamental uncertainty
Necessary performance variability
Tendency for system ‘drift’
No need for complication!
8
![Page 9: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/9.jpg)
Where does all this get us?
Humans need to ‘complete the design’
We do so by deciding what’s ‘good enough’
‘Good enough’ depends on our SUGAR mix
Our SUGAR mix changes with each decision
Premises
9
![Page 10: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/10.jpg)
Where does all this get us?
Help individuals understand and resist toxic SUGAR mixes
Warn organisations when things are going wrong systemically
ConclusionsSo, it would helpful to have tools which:
10
![Page 11: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/11.jpg)
Where can we find such tools?Resilience engineering
“the quality of a system that allows it to maintain its stability in the face of constant disruption”
What is resilience?
11
![Page 12: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/12.jpg)
How can we measure resilience?
Buffering
12
![Page 13: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/13.jpg)
How can we measure resilience?
Flexibility
13
![Page 14: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/14.jpg)
How can we measure resilience?
Margin
14
![Page 15: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/15.jpg)
How can we measure resilience?
Tolerance
15
![Page 16: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/16.jpg)
How can we measure resilience?
Discord
16
![Page 17: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/17.jpg)
How can we measure resilience?
Discord
Tolerance Margin
Flexibility
Buffering
Examples?
17
![Page 18: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/18.jpg)
In summary – four key points
We can only view things based on our dynamically changing SUGAR mix
We ‘complete the design’ based on our current SUGAR mix – which determines ‘good enough’
We need to focus on resilience rather than human error
We need to develop resilience indicators to tell us when the system is becoming unsafe
18
![Page 19: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/19.jpg)
Being Human in safety-critical organisations
Dik Gregory and Paul Shanahan by
Available in July 2017
Sponsored by UK Maritime & Coastguard Agency BP Shipping Teekay Shipping Standard P&I Club
19
![Page 20: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/20.jpg)
Part Two
Practical steps towards resilience
20
![Page 21: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/21.jpg)
Why do people often know about safety problems, but nobody does anything?
Some real-life examples of senior manager trade-offs gone wrong
21
![Page 22: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/22.jpg)
22
![Page 23: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/23.jpg)
The blazing Zafira
23
![Page 24: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/24.jpg)
Unnecessary baby deaths
24
![Page 25: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/25.jpg)
Collapse of Barings Bank
25
![Page 26: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/26.jpg)
Looking at your own trade offs
Take a few minutes to discuss a safety-related trade off you have made in the past
How were you influenced by your SUGAR mix at the time?
Each come up with the three factors that most influenced your trade off
How far did you have the knowledge and skills to solve the problem at the time - and why (not)?
What were your goals at the time, how clear-cut were your priorities - and why (not)?
How safe did you feel at the time - and why (not)?
What sense of obligation did you feel at the time - to whom - and why (not)?
How pressing did the problem seem at the time - and why (not)?
Questions that may helpTask
26
![Page 27: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/27.jpg)
What can you do – now – to increase your organisation’s resilience?
Take a few minutes to brainstorm actions that could increase the resilience of your organisation
Each come up with the three actions that you could realistically take to increase resilience
What’s the difference between management perception and operator experience of safety-critical work - & how do you know?
How far does everyone work with shared priorities and values - & how do you know?
How often do people report a safety issue and what happens when they do?
How hard are people working to achieve their agreed objectives, how has this changed over time - & how do you know?
What are the main sources of pressure on the people who work in your organisation, how well are they coping - & how do you know?
How are your safety performance boundaries defined, how were they validated, where is everybody with respect to them - & how do you know?
How often are people surprised by events, how well do they deal with them – & how do you know?
Possible considerationsTask
27
![Page 28: Part One Understanding human performance in complex systemshelioffshore.org/.../05/Day1_04_Human-Factors-TO-BE... · Being Human in safety-critical organisations Dik Gregory and Paul](https://reader033.fdocuments.net/reader033/viewer/2022051322/60203b35fb5e1e79066049a6/html5/thumbnails/28.jpg)
Final observationsGretchen Haskins CEO, HeliOffshore
28