Ron Whalen
It would be reasonable to expect that as the world becomes increasingly
technologically sophisticated the risk of major disasters would reduce…..
but statistics suggest otherwise.
Out of the 30 worst industrial accidents to occur in the past 100 years
(in terms of number of people killed or millions of dollars of damage),
15 have happened in the last 20 years.
Progression of technology means a progression of machines where they are ! Smaller ! Faster ! More accurate Than what humans can be
Enter the shi/ worker…..
The Shi/ Worker
! Long hours with a partner, that you don’t choose and may either like or dislike working with, yet it is expected that you work well together as a team and ensure a safe environment.
The Shi/ Worker ! Control Rooms now consist of people with different religions, accents, cultures and habits
! Different work experiences and qualifications, often poached from other companies
! Automation risks deskilling Operators
! Field crews trust and rely on Operators to have arranged a safe work location for them.
The Shi/ Worker ! Lots of distractions these days in rooms
! Routinely repetitive and boring tasks for a lot of the time but expected to perform magnificently in extraordinary critical incidents – and be able to tell the difference between the two
! Training (getting what they need)
! Discipline to ALWAYS follow procedures can be a problem
Situa7onal Awareness
! The accuracy of a person’s current knowledge and understanding of actual conditions compared to expected conditions at a given time.
Situa7onal Awareness
! What are the things that can affect the amount of situational awareness an Operator can have?
Expert v Novice – Prof Wiggins
Fa7gue & Rosters – Mark Holmes
Changing need of Quals
But what we learn is being outdated
For students star7ng a 4yr technical degree
Half of what they learn in their first year of study
Will be outdated in their third year of study
Room Design – Russell Ockendon
Slide 18
Summary
Human Performance
We learn from incidents
Human factors
! study of all aspects of the way humans relate to the world around them,
! with the aim of improving operational performance, safety, or adoption through improvement in the experience of the end user.
Some7mes it is the Human
Cogni&on
! What are you thinking about? ! Working memory versus Long Term Memory
! Experts versus Novices
Mental Model
! One’s understanding of a system, how it operates, its characteristics, performance parameters, couplings within itself and other systems and how one interacts with it.
Mental Model
! It is a representation of the surrounding world, the relationships between its various parts and a person's intuitive perception about his or her own acts and their consequences.
Mental Model
! Our mental models help to shape our behaviour and define our approach to solving problems (a personal algorithm) and carrying out tasks, especially within a system.
Mental Model
! Mental models are like opinions, they can be partially or completely right or wrong, complete or incomplete and most often are unique for each individual.
Decision Making
! Information overload ! Experts vs Novices ! Biases
Informa7on Overload
Bias
! Assumptions – A condition taken for granted or accepted as true without verification of the facts.
Bias
! Habit – An unconscious pattern of behaviour acquired through frequent repetition.
Bias
! Confirmation bias – The reluctance to abandon a current solution
! To change one's mind—in light of conflicting information due to the investment of time and effort in the current solution.
! This bias orients the mind to “see” evidence that supports the original supposition and to ignore or rationalize away conflicting data.
Bias
! Similarity bias – The tendency to recall solutions from situations that appear similar to those that have proved useful from past experience.
Audio visual examples
! New York Blackout 2003
! Three Mile Island 1979
! AF 447 2009
! QF 32 2010
Slow things down ! All human performance tools deliberately slow things down to ultimately speed things up by avoiding delays that accompany events triggered by active errors.
! When used conscientiously, these tools give the individual more time to think about the task at hand; about what is happening, what will happen, and what to do if things do not go as expected.
! Have a conversation
! Be disciplined and follow the process
Where to from here…..? ! Simulation Training ! Review what training you do to see if it is achieving what you really need
! Look, Listen and Talk – your Operators are demonstrating to you every day their strengths and weaknesses
! Maturity and attitude to report near misses etc for future improvement and training
Classifica7on of errors
! Human Error Classifications ! Skill Based ! Rule Based ! Knowledge Based
! Often we will operate in all three levels, going back and forth in a single event.
Back to Six Human Considera7ons
! Attention ! Sensation ! Perception ! Cognition ! Decision making ! Action
Considera7ons Broken Down
There's a need for accep7ng responsibility -‐ for a person's life and making choices that are not just ones for immediate short-‐term comfort.
You need to make an investment, and the investment is in health and educa7on.
Buzz Aldrin