How does one fight complacency in everyday tasks? 9

[Boiler1]

Hello,

Lately, for no apparent reason the organisation I’m working at experienced a series of incidents, mainly to human error.
It’s the same team, the same procedures in place and yet the focus somehow seem to periodically slip away. None of the incidents had an H&S impact, however all had caused a downtime in the process.

In some instances, people have even skipped the procedural steps in assessing and documenting the risks as they have done the same task dozens of times.
After each rough patch the same thing is repeated – procedures are updated to catch the likes of the latest incident and more training introduced.
This works for a while and then the complacency ( I believe) takes over causing more incidents.

Is there any ‘magic wand’ to stay on top of peoples focus on everyday tasks. Any proven methods?

Regards

 

[RedSnake]

My experience after 30 years with similar problems is.
1. No one reads the instructions.
2. Those who have to ensure that their subordinate staff perform the job according to the instructions do not perform their part of the job.
3 It usually ends up with those who have a leading responsibility wanting to program the problems away, ie make sure that the machine can not be handled incorrectly.

We usually say they want to solve the soft questions (managerial control) by solving the problem with hard constructions (which costs more) instead of the management properly following up that instructions are followed.

If you do not have an organization that has the same view and attitude to this all the way from the top down to the bottom, it is difficult.

Unfortunately, I can not give you a magic wand. :-(

Best Regards A

“Logic will get you from A to Z; imagination will get you everywhere.“
Albert Einstein

 

[1503-44]

I can give you the magic wand.

Training under a "do once, forever remember" concept will simply never work.
Repetition breeds complacency.
Complacency is like a bomber's thumb button. Take your finger off the button, it explodes.
The military, at least most of it, does not fight a war every day.
What they do EVERY DAY is training.

Safety and procedure training or discussion every morning.
Review procedures and safety before the start of every task.
Recap lessons learned and suggestions to improve every night.
Do again

 

[byrdj]

"Ive done this a thousand times . . ."

Spoiler

http://4.bp.blogspot.com/_t8BRe_gEVWo/R6vKSvlMmwI/AAAAAAAAAA4/DH0smhoE1lM/s1600-h/deadbv27dec7.jpg

 

[RedSnake]

As a darwinist I get the picture
Unfortunately we have other rules to abide too ;-)

BR A

“Logic will get you from A to Z; imagination will get you everywhere.“
Albert Einstein

 

[Alistair_Heaton]

I will throw some words at you to go and google from aviation which might give you a few ideas.

Crew resources Management abbreviated to CRM

Threat Error Management abbreviated to TEM

There has been loads for stuff done by NASA on this subject. And it does work.

To get it working you have to get everyone to buy into it. Its also being used in surgery a lot these days and giving positive results.

 

[RedSnake]

1503-44 and Alistair
I agree with you.

But sadly this only works if you have an organization that has the same view and attitude to this all the way from the top down to the bottom.

So the question to Boiler1 is, do the organisation you are in, have this attitude or not.

Best Regards A

“Logic will get you from A to Z; imagination will get you everywhere.“
Albert Einstein

 

[1503-44]

Org learns best from the bottom up. What you hear coming from the top is the echos from the trenches bouncing off the ceiling with a significant phase lag.

 

[Alistair_Heaton]

In airlines CRM is often facilitated by cabin crew. Although there are some areas which are Captains only course's given.

Everyone does it, be they operations, ramp crew or technical. The techs have an additional module to do with their error threat profile. The tech crew course might be worth looking at.

It's not meant to teach you, it's meant to make you think as a mixed group.

It all came out from the KLM teneriff 747 accident.

 

[bones206]

When I worked in the nuclear power industry, training was pretty extensive. Most of that training was mundane and had to be repeatedly drilled into you or else was easily forgotten. But the Human Performance and the Situational Awareness training have stuck with me over the years for some reason. I'll find myself subconsciously doing the Stop Think Act Review (STAR) process all the time, even now almost 6 years since I left the industry. I think that happened because the nuclear trainer emphasized how to apply the method in everyday life, outside of work. Seeing how it could benefit me outside of work helped me buy into it at the time, and applying it repetitiously over the years has turned it into a second nature kind of thing.

I imagine the aviation industry programs that Alistair shared are probably the same principles as those used in the nuclear industry, just with different acronyms.

 

[Alistair_Heaton]

They are mostly the same just tweaked for the industry.

We use that one as well.

There is a difference between single crew and multicrew for us.

I had forgotten that nuclear had bought into CRM as well. It started with aviation and NASA.

And it does take over your life after a while and it does work with pretty much everything apart from the wife. If you use it with them it's like throwing petrol on a fire.

 

[davefitz]

Perhaps plotting the number of incidents vs days of the week might yield a clue. There has always been an urban myth that cars built on monday and friday always have the most defects, related to hangovers etc.

If you are superstitious, then plotting events vs the phases of the moon would be your go-to method of correlation.

In general, each person on a team has a family life after work that affects their work performance, and that adds a certain amount of random chaos to correlating behavior patterns. There is also the impact of recreational drugs, alcohol, binge watching netflix, co-workers' suggestive clothing distractions,estrus cycle, etc.all affect workers concentration. There can also be environmental factors such as O2 or CO levels if it is indoor air. There may be a standard test one can give the worker every day to test thier level of concentration, such as a video game to see how long it takes them to get to the next level of super mario.


"...when logic, and proportion, have fallen, sloppy dead..." Grace Slick

 

[Alistair_Heaton]

CRM goes into all of these factors.

There is a thing called a SHELL model of human factors

It actually saves money having a good CRM continuous training running.

It also links in with occurrence reporting systems. After a couple of years people reporting then it's pretty obvious where to target training or change systems of work.

It really pisses off some managers because it's hard facts and an accountancy cost can be attributed to a personal preference for doing things in a certain way.

 

[cranky108]

Some of it may also be related to group memory. New people may not learn that memory unless it is repeated. And unless you reinforce the need to do, what may seem like worthless steps, they may be skipped.

Group memory is a set of stories that get told, and usually people that maybe made fun of because of events.
The guy that tests for non-operating relays, by tapping on them with the back of them with a screwdriver. It works, until you tap on the back of a 63X relay (that is very sensitive, and may pickup). The results are a lot of circuit breakers opening.
Yes it is a third hand story, from a different company, but, it works.

 

[phamENG]

It's been a few years, but I worked in nuclear power when I was in the Navy, and this was a constant battle. Whoever runs your safety and or training departments needs to have a creative streak. If they are just in it to the check the box, then complacency will overwhelm the operation. Not sure if you're talking about operations or maintenance, but I have a few thoughts:

1) Operations - training drills. Come up with simulated failures/faults/problems with your operational process, and get your team to respond to them. If they can be "surprise" drills, so much the better - but that can be hard to do without interrupting the process or potentially damaging equipment. Knowing and being reminded of what can happen and how to handle it will (hopefully) help to keep it fresh in everyone's minds that they need to be careful.

2) Maintenance - spot checks and audits. We had procedures for everything. We would have random spot checks where a supervisor (from the lowest level all the way up to the ship's Captain) would show up for your maintenance and watch you do it. The higher level checks had to be carefully scheduled, but the lower and middle level checks could be truly random - even in the middle of the night if it was taking place on the night shift/mid-watch. As a result, everyone prepared properly for their maintenance, had the right tools, parts, etc. For audits, keep a paper/electronic trail. Have a print out of the procedure that a low level supervisor or experienced team member uses to initial each step of the procedure. Failure to file it would count as a failure to perform the maintenance. If anything goes wrong, there's accountability. Of course, that accountability has to be proportional to the incident. I don't like that this is all stick and no carrot, but in the US OSHA forbids rewards for good safety records to discourage falsified records.

 

[bones206]

Agree completely with creative training drills. At Grand Gulf in Mississippi they had a training building with a mock plant layout. The drill was to make your way through without "dying". Not many people made it through "alive" in my group, which has a way of leaving an impression in people's mind . The drill instructor would make nonchalant commands and people would instinctively obey without going through the STAR process first. Then they would be informed that they just walked into a hazard and were currently suffocating (for example). The drill instructor would say something like "quick, save her!", and 2 or 3 people would go to make the rescue, only to be informed that they too were now goners. Second time through, people were stopping to think and make themselves more situationally aware and conscious prior to acting. That was 12 years ago, and I still distinctly remember that day, the instructor and the faces of the people in my group! Immersive training is great.

 

[LittleInch]

I do like that STAR principle - looked it up and there's all manner of ideas, posters, training course etc.

The near miss reporting thing can be diffcult to get right and not have everyone looking over their shoulder all the time, but as everyone's says, it's got to be the culture of the place from top to bottom.

A great example of something that in real life took less than 5 seconds was the testimony of the medical car that follows the first lap of the Grand Prix.

In Bahrain this year one car went through the crash barrier and burst into flames.

The medical car driver said afterwards We stopped and had a quick conversation about what we were going to do and who was going where. In 5 seconds they stopped, thought, acted and then reviewed later.

So it doesn't have to be tedious and time consuming, but part of what you do.

A simple thing which is now common practice in many locations is reverse park. I just do it as standard and have tutored the other half into it as well and she understood why and what the benefits were.

Only when people really see the benefits to them will it change. Sure we are all concerned about our fellow man/woman on the job, but deep down, 75% of the concern is for yourself.

Remember - More details = better answers
Also: If you get a response it's polite to respond to it.

 

[EdStainless]

Physical checklists. We used them for set-up and maintenance procedures, they were also built into nearly all operations procedures.
The people on the team had defined rolls for that task, these rolls changed from day to day and task to task.
Someone was lead, someone read the checklist, someone verified that things were done.
We crashed a set of $100k tooling on set-up before this was put in place.

= = = = = = = = = = = = = = = = = = = =
P.E. Metallurgy, consulting work welcomed

 

[RedSnake]

The one colleague of mine who taught me the most about safety thinking and safety around performing maintenance and also about the operation of the machines themselves and who was also was my boss for a while.
He started as an electrician at a nuclear power plant, and I am quite shore that was where he was thought this way of thinking.
Never met anyone else at my company with his mindset and most others just thought he was annoying. :-(

That activities such as aviation, nuclear power plants and I could imagine oil platforms have a security mindset that permeates the organization is to some extent due to legislation and also because the risks are very obvious and catastrophic to many when they happen.

Even though industries have the same number of laws to comply with, it is much more about assessments and the external control is less.
And with so many different equipment's in one place and new managers and new reorganizations and new philosophies every 5-6 years it becomes completely impossible to keep a straight line or hold on to something long enough for there to be any real "order" to things.
At least where I am at.

Best Regards A


“Logic will get you from A to Z; imagination will get you everywhere.“
Albert Einstein

 

[bones206]

Given that the OP mentioned things have gone south at their organization just recently, it could be related to the pandemic. The mental fatigue of it all is just withering.