Todd Conklin, PhD

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Todd Conklin, PhD Safety Improvements Initiative
Office Los Alamos National Laboratory
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Never take a sleeping pill And a laxative at
the same time. In any order
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Dont ever remove A safety barrier that has a
dent in it.
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Start Of Job
Mission Success
Work as Planned
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Your workers are as safe as they need to be,
without being overly safe, in order to do their
work.
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Or Are They..
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Human Error Expertise Identification Exercise
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• How many times does the uppercase or lowercase
  letterFappear in the following sentence?

Finished files are the re- sult of years of
scientific study combined with the experience of
many years.
Finished files are the re- sult of years of
scientific study combined with the experience of
many years.
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Limitations of Human Nature

• Mistakes arise directly from the way the mind
  handles information, not through stupidity or
  carelessness.
• -Edward de Bono PhD

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Everything Becomes Obvious Once You Know The
Answer.
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Start Of Job
Mission Success
Work as Done
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Safety Perceived

• We respond to the feeling of safety not the
  reality of safety
• Most of the time these are the same
• Until they are not
• People make trade-offs based upon the feeling of
  being safe.

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Events dont happen often enough for us to learn
why events happen
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Workers FIND Safety at Work
Clearly Safe to do Work
The Gray Area Uncertain interpretation of Safe
work
Clearly Not Safe to do Work
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After the Event, Safety is Clear
Success
Clearly Safe to do Work
Clearly Not Safe to do Work
Event
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Start Of Job
Event
Hazard
Accumulation of Hazard
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Four Philosophical Ideas
Your work is always Adaptive You discover work
in the field Remember these 4 things
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• Small things that go wrong are most often early
  warning signals of deepening trouble that provide
  insight into the health of the whole system-and
  signal strength matters.

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Treat near-misses and close-calls as immediate,
preventive information about the health of the
system and try to learn from them. Value
them. All Prevention Happen Through Learning.
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Understand that when you catch problems before
they grow bigger, you have more possible
solutions and are much more powerful.
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• Imagine what is going to happen as you are
  planning and preparing to work.
• What could surprise you?
• What could happen right?
• What may go wrong?
• What hazards did we think of?
• What hazards could we discover?
• What can you Detect and Correct?

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Safety is not the absence of accidents. Safety
is the presence of defenses.
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You Manage Risk in order to Keep Failure From
Being Successful.
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