The Misfortune Murphy Model

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The Misfortune Murphy Model

• Will help us understand how human errors result
  in accidents
• Will assist us in understanding the root causes
  to an accident
• Will illustrate the role of Safety Management
  Systems (SMS) in preventing accidents
• Will help us understand what WE can do to help
  prevent future accidents

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The Original Swiss Cheese Model

• Developed by James Reason 1990
• Is recognized world wide as an error model
• This model has been adapted and updated many times

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Latent Conditions
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Management Decisions

• Management Decisions set up Latent Conditions

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Latent Conditions
A system condition (policy, decision or norm)
that lays dormant until an active failure
normally brings it to light They are there but
often not recognized as dangerous until too late
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Management Decisions

• Management Decisions set up Latent Conditions

• Set the scene for the Active Failure to occur
• Seem like good ideas at the time
• May lay dormant for a long time
• When all the conditions are wrong an accident
  occurs if there is no Safety Net to stop it.
• The Safety Net may be present however it has a
  hole in it (not being followed)

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Latent Conditions
Latent Conditions
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Line Management Decisions

• Line Management Decisions Latent Conditions
• Are decisions made based on what they think the
  management really wants
• Are there but are not recognized as potentially
  dangerous
• May also lay dormant for a long time
• When all the conditions are wrong an accident
  occurs if there is no Safety Net to stop it
• The Safety Net may be present however it has a
  hole in it (not being followed)

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Latent Conditions
Latent Conditions
Latent Conditions
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Preconditions - The Dirty Dozen

• Set the person up to make the active error
• Are often a combination of more than one of the
  Dirty Dozen

7. Lack of Resources 8. Pressure 9. Lack of
Assertiveness 10. Stress 11. Lack of
Awareness 12. Norms
1. Lack of Communication 2. Complacency 3.
Lack of Knowledge 4. Distraction 5. Lack of
Teamwork 6. Fatigue
Preconditions To a Human Error
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Active Failures
Latent Conditions
Latent Conditions
Latent Conditions
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The Active Failure

• The guilty party who makes the mistake that
  results in a human error
• It will be an action or lack of action that
  results in the error
• It is the RESULT but NOT the CAUSE

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Active Failures Are Usually Productive Activities
That Involve an Unsafe Act

• Is usually very experienced
• Has no intention of making the error (He knows
  better)
• Often has no idea how he could have been so
  careless
• Will often punish himself more than the system
  can
• Is very unlikely to ever do it again

The Guilty Party
The Guilty Party
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Active Latent Failures
Active Failures
Latent Conditions
Latent Conditions
Latent Conditions
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Safety Nets

• Last chance to prevent the accident from
  occurring
• If there is no Safety net in place then it is a
  Latent Failure
• The Safety Net may be present however it has a
  hole in it (not being followed)
• If the Safety net is not being used it is an
  Active Failure

How many times does the chain of events get all
the way to the Safety net and is stopped there?
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Active Latent Failures
Active Failures
SMS Incident Drip Tray
Latent Conditions
Latent Conditions
Latent Conditions
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The SMS Incident Drip Tray

• Serves to catch the near misses that could have
  continued on to cause an accident
• Requires someone to fess up and report the
  near miss
• Requires a system to take and analyze (risk
  assess) the data in the drip tray
• The system will then use this information to
  plug or reduce the size of some of the holes
  that allow the chain of events to occur
• This results in fewer accidents
• We learn from an accident we didnt have

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10-20
80-90
Active Latent Failures
Active Failures
SMS Incident Drip Tray
Free Lesson Tray
Latent Conditions
Latent Conditions
Latent Conditions
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YOU Are the Key to Safety

• YOU are the person who has the near misses
• YOU are the one who can put information into the
  Incident Drip Tray
• YOU can provide the information that will help
  plug the holes
• YOU can provide the Free Lessons that enable
  the organization to learn without having to have
  an accident
• SMS will require YOUR input to work

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Any Questions?
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For More Information - Contact
System Safety Services 23100 Willett
Ave Richmond, BC Canada V6V 1G1 Phone/Fax 604
526-3993 Email Dupontg_at_system-safety.com Website
www.system-safety.com
We are always pleased to provide your company a
briefing on how to reduce human error for costs
only Why not give us a call
It is a question of Safety