The Misfortune Murphy Model Will help us understand
- Slides: 19
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
Latent Conditions
Management Decisions • Management Decisions set up “Latent Conditions”
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
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)
Latent Conditions
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)
Latent Conditions
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 s n o r i t 8. Pressurero 2. Complacency i r d E n 9. Lack of Assertiveness 3. Lack of Knowledge o n c a e 10. Stress 4. Distraction r m P u 5. Lack of Teamwork H 11. Lack of Awareness a 12. Norms 6. Fatigue o T 1. Lack of Communication 7. Lack of Resources
Active Failures Latent Conditions
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
Active Failures Are Usually Productive Activities That Involve an Unsafe Act • Is usually very experienced The “Guilty Party” The Guilty Party • Has no intention of making the error (He knows better) better • Often has no idea how he could have been so “careless” careless • Will often punish himself more than the system can • Is very unlikely to ever do it again
Active & Latent Failures Active Failures Latent Conditions
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?
ip ay r T Active & Latent Failures Active Failures nt Latent Conditions e cid n I Latent Conditions S SM Latent Conditions Dr
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 didn’t have
10 -20% 8090% ra ip T r n. D ay r y. T Active & Latent Failures Active Failures sto Latent Conditions n s e i. Lde c e Ien r Latent Conditions F S SM Latent Conditions
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” 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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