Incident pit

Transcription

We expect a lot of our LAMEs. We put them in as, you know, what Dr Alan Hobbs and Professor Reason have labelled as, you know, one of your more error-prone working environments. We expect them at times to do routine tasks and to deliver close to a 100% solution. And at times we expect the 100% solution. It's a bit like we saw the part that broke during the repair. That's not going to work well, that's not going to sit well. We expect someone to turn up in the environment, deliver an outcome and hopefully get it right first time for the efficiency and effectiveness of the organisation. There's a couple of things we know and it's certainly based on the work of Dr Tony Kern, but we know that lost situational awareness has got three primary factors from some research that will help you understand when you're likely to actually lose an understanding of what's happening around you which can lead to that tunnel vision and all of a sudden you're blind to the things going wrong and that's when you've gone too far. But number one is distractions. Number two - time pressure. And then number three - breaking habit patterns. And we know for a fact if there's distractions, unacceptable use of mobile phones when you're meant to be doing critical tasks, interruptions from people that really don't need to be talking to you at the time, it could be distractions from family. The wife's calling up 'cause she needs to find the credit card, you know, which if you happen to be carrying your mobile phone, all of a sudden you're going to pick up the stress of you worrying about what's going on at home and even less likely to focus on the job. Time pressure - it's the nature of where we work. You know, we have outcomes that have to be delivered in a set time and time pressure is a prevalent part, but most of us can probably say take away the time pressure and I won't lead myself down that little environment where I start doing some stuff and I'm not realising I'm doing it wrong and then finally broken habit patterns. And this is fundamental. You have to be instilling the right habit patterns from your people from the moment they walk into an organisation 'cause if you don't have them in the first place, how do you recognise you've broken it? The good thing is, strong habit patterns is a really, really direct means to actually for individuals to detect that I've just moved away from something that's quite normal for me, you know. If that happens to be that when you're regularly turning... It might be something as simple as when you turn up, I always put my smoko in the fridge and then I'll go and make a coffee and then I'll quickly check something. It could be as simple as you walk in and you've left your smoko sitting on a bench and you're distracted doing something else. It's not related to the task. But for the last, you know, five or six days in a row, you walk in and you regularly put your smoko straight in the fridge, get your coffee, you're already thinking, "Is something on my mind? It's not going quite as it would normally." It's those early cues, as early as possible, where you say, "I'm just not following my normal routine," that potentially will give you insights that you're not quite where you need to be. It's not to say you can't do the job, but it is certainly time to start having that discussion with other workers or with a supervisor about how you're going to do the job safely. Another common trend, we see some systems, particularly where you're busy. You know, where you've just got to deliver output. Who do you tend to pick to do the jobs, to do those more difficult, challenging tasks? Just have a think about it. Who do you pick? You've probably got what you consider is the A-team, the go-to someone - you go straight to them, they get the job done. I've had to investigate numerous serious incidents where, not only the go-team completely mess up the situation, the go-team actually encouraged and produced a culture that was significantly detrimental to the organisation. Let's think about why. So we go to the A-team, the go-team, the person that gets the job done. Often they've got ways to shortcut the system. They're happy because they've got pride. Boss comes to see them. They've got an expectation, a perception, that they will get the job done. And sometimes that in itself is a precondition to do things the wrong way, to take a shortcut, to not follow the book. The second thing is what about all the people you want to allow opportunity to become the A-team? And often what you find when people get busy, you load up your already busy and fairly experienced workers, and your young, new, you know, apprentices are sitting there going, "I wish I could get my hands on the tools." If you don't get that balance right, you end up in a very, very serious situation where your young whippersnappers don't want to be there, they've got low morale, they're not getting the time on tools to actually learn to become the A-team, and at the same time, you start, one, burning out your A-team, and, or, two, you start letting your A-team demonstrate behaviour as role models that you really don't want to be demonstrating to the junior personnel. GARVIN: What I found interesting about 'Crossed Wires' is the way that it emphasised the fact that it's very, very seldom that one thing goes wrong. It's always usually an accumulative effect. In diving, we call it the incident pit. And typically what will happen if something goes wrong during a dive is one early thing will be slightly out of point and somebody has missed that or has decided to ignore that very early on. And as a result of them doing that, then the second incident will happen which is then compounded. And then a third incident will happen. And slowly it's the sequence of all of these worsening incidents that finally causes something that can be extremely serious or fatal. And it was the same for the Deepsea Challenger Project. It was very rare that we had one instrument suddenly failing or suddenly deciding to go amiss. It was always usually a few warning points that were usually picked up by us beforehand that gave us an indication that that would actually happen. So I think what I have learnt from very complicated systems like the Deepsea Challenger is to ignore the small minutiae at your peril. If there is something in the back of your head that just doesn't quite feel right, or you're even having to think twice about a certain system, then you should listen to that instinct because chances are it's about to fail, something is seriously wrong. As the day of the big dive approached, the pressure that the team on board the ship came under was tremendous. Not only did we have the environmental pressure, we were out in the middle of an ocean that was moving all the time and we had to conduct work in very, very tight, confined spaces. We also had the increasing pressure of the timing of the dive. We had a very short weather window in order to get the sub launched, get the dive done and then get back out. And on top of that, we had this big 3D cameras literally in your face day and night filming everything and scrutinising everything that you did. So it was essential during that time that the team on board the boat really worked closely together. You really had to trust the guy to your left and the guy to your right to help you, to support you, to miss any things that you might've missed. And this incredible close-knit team kind of came aback from that attrition, really, which is what it was out there. And it was fantastic. If one department had problems or issues, then people from the other departments would turn up and would say, "How can we help you? "How can we throw our resources into your department to try and fix that?" And together as a team, we collectively managed to pull the dive off.