Session:Wednesday7October2:40pmTapRooTSummitNashville2009

Behavior dependsonRiskPerception

By JimWhiting risk@workplaces.com.au

HumanGOOFUpsarealways [100%not90%or95%] partofcausationofrealincidents andalways partofcausesofrisksofwhatifincidents. GOOFUpsoccurwhenwedontdowhatweare: ! Supposed todo ! Should havedone ! Could havedone ! Wanted todo ! Tried todo ! Needed todo ! Told todo ! Expected todo ! Obliged todo ! Trained todo

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QRA.27

Lesserrorpronedesign? Nowdesignisergonomic

VisionDecrementwithAGE

Age 20

Age 60

Age 75

RiskPerception AvoidOverConfidence

RememberEVERYTHINGispossible butsomethingsaremoreprobable thanothers Bewaretheblackswan AvoidAbsolutewordslike: eliminate,stop,prevent,zero Wereducetheriskofrecurrenceofincidents Wedontprevent them

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AvoidOverConfidence
1907 "WhenanyoneasksmehowI canbestdescribemyexperience innearlyfortyyearsatsea, Imerelysay,uneventful.

Ofcoursetherehavebeenwintergales,andstormsandfogandthelike.Butinall myexperience, Ihaveneverbeeninanyaccident...ofanysortworthspeakingabout. Ihaveseenbutonevesselindistressinallmyyearsatsea.Ineversawawreck andneverhavebeenwreckednorwasIeverinanypredicamentthatthreatened toendindisasterofanysort.

5Yearslater,1912CaptainSmithwasMasteroftheTitanic onitsonlyvoyage.
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RMcannever evenconsider copoutconcepts suchasbadluck

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BlackSwanPrinciples
Whenitcomestogeneralizationslike allswansarewhite,itis enoughforoneblackswantoexistforthisconclusiontobefalse. BEFOREyoufindtheblackswan, noamountofinformationaboutwhiteswans whetheryouobserved1,100,or1,000,000ofthem couldhelpyoutodeterminewhetherornotthegeneralization allswansarewhiteistrueornot.

BlackSwanPrinciples ! Beyondanypastpersonalexperiences? ! Believedtobeimpossible?Improbable? ! Low[orZero?]Likelihood? ! RisksthatarelowLikelihoodbuthighConsequence

ExamplesofBehaviour dependingonRiskPerception
! Swedendrivingontheright ! Electricallinesmenworkingafter/duringa nightstorm ! Streetlightsoutanintersection ! USsubmarinecaptainsearlyinWW2 ! Isthereaneconomicequivalentofwartime risktakinginstressedcompanies?

HumanGOOFUpsarealways [100%not90%or95%] partofcausationofrealincidents andalwayspartofcausesofrisksofwhatifincidents. GOOFUpsoccurwhenwedontdowhatweare: ! Supposed todo ! Should havedone ! Could havedone ! Wanted todo ! Tried todo ! Needed todo ! Told todo ! Expected todo ! Obliged todo ! Trained todo copyright 2009 risk@workplaces pty ltd

QRA.27

GOOFUpscanbeeither: ! intentional (substandardpractices,unsafeacts,atrisk behaviours,violations/breachesofrulesOR ! unintentional (errors,mistakes,nochoiceorintentand sometimesnoteventawareofthecorrect behaviour). Human Errors often defined as the goof-ups where there was no choice or intent
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QRA.27

Human Errors
Human Reliability Analysis identifies various types of human errors:! error of omission not carrying out the required action; and ! error of commission
! difficulties in carrying out a required action adequately; ! too much or too little force ! without the required accuracy ! carried out at the wrong time ! carried out in the wrong sequence the required action.

! perform other extraneous actions; ! un-required actions carried out instead of or in addition to,

error-tolerant and error-recovery actions and parts of systems or procedures where there are opportunities for human or mechanical actions to recover from previous errors. ! HRA depends strongly on behavioural sciences, ergonomics, human factors engineering and reliability engineering.
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! HRA identifies

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Human Reliability Analysis (HRA)

Human reliability analysis (HRA) considers how humans interact with their tasks, equipment, tools, work methods and work environment. The human element and its effects on other parts of any system are the most unpredictable; hence most unreliable part of any system. This makes the estimation of probabilities of human error notoriously difficult. Human interaction provides both positive risk treatments and the errors which influence system performance, safety and productivity. Human action is often the only defence in preventing an incident scenario progressing fully to its unwanted outcomes.
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Human Reliability Analysis (HRA)

" SituationalAwareness&associatedRiskofErrors

areimportantaspectsinriskperception/identification
" Riskofanindividualmakinganerror:
! isoftenrelatedtothepersonsblindnesstothesituation

" Situationalawareness:
! apersonsperceptionofwhatriskfactorsarepresentorabout

toariseintheworkenvironmentatanymomentintime ! thepersonsunderstandingoftheirpotentialeffectsbothinthe immediatepresentandfuture

Behaviour depends on Risk Perception

The ultimate Activator A of behaviour is the persons perception of the level of risk of negative and positive consequences associated with the situation and the use of certain types of behaviour

Perception of risk is a function of: how much the person believes he/she is personally exposed and susceptible to harm (It wont happen to me) personal experience with the situation or task and observation of others in the same situation how much the person believes the outcome is serious how much the person believes that control actions would be effective and worth it.
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E.18

Behaviour and Risk Perception

To be confident that employees at all levels understand and may possibly want to or need to change their risk taking behaviors at work, we need to be confident that they can understand & evaluate the risks adequately, AND perceive the risks adequately AND assess the risks adequately AND calculate the risks adequately.
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AAA.9

An individuals or workgroups tolerability of risk

depends on personal evaluation of costs / benefits based on values & perceptions at all levels : personal, family group, corporate social
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Perception Factors for Risk Tolerability

Perceived as more tolerable ! voluntary / internal / choice ! under own personal control ! benefit to exposed person ! natural components ! effects appear stat. certain ! negative effects delayed ! familiar characteristics ! equitable, fair distribution ! minor consequences ! Info from a trusted source ! targets adults ! assoc with benign words Perceived as less tolerable ! externally imposed ! controlled by others ! little or no obvious benefit ! synthetic / artificial ! effects statistically uncertain ! negative effects immediate ! unusual, exotic ! inequitable, unfair distribution ! catastrophic consequences ! Info from a non-trusted source ! targets children ! associated with dread words
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E.17

PossibleRiskTolerabilityversusLevelofPerceivedRisk
"riskavoiders" "riskreducers" "riskoptimisers" (avoidactivitiesduetotherisksinvolved), (participateinhighriskactivitiesinspiteoftherisksinvolved), (participateinhighriskactivitiespartlybecauseoftherisksinvolved).

Highly Tolerable

Risk Optimiser

Neutral

Risk Reducer Risk Avoider

Highly INtolerable Low

LevelofPerceivedRisk

High

personalitytraits?? attitudesarepredictedtobereasonablystableovertime

" On a day-to-day basis, the risk takers and the risk makers are the appropriate risk managers. " However , this assumes that :the risk takers and the risk makers fully know and fully appreciate all the positive and negative dimensions of the risk.

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E.20

ALL safetydiscussions " safetymeetingsofanykind " postincidentdecisionmaking " employeecounselling " observationbasedinteractions " workmethoddiscussions shouldinvolveriskassessmentstoachieve ! alignedriskperceptions ! employeeownedprocedures
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Four BehaviouralConceptsorPerformanceDifficulties
afterMarx:PatientSafetyandtheJustCulture:APrimerForHealthCareExecutives MedicalEventReportingSystem TransfusionMedicine(MERSTM)4/17/01

1.HumanError

HumanErrorisasociallabel.Humanerrorisatermthatweusetodescribeoureveryday behavior missingaturnoffonthefreeway,pickingupstrawberryicecreaminsteadofchocolate. Thethresholdforlabelingbehaviourhumanerrorisverylow wemakeerrorseverydaywithgenerallyminimalconsequences.

2.NegligentConduct
Negligence,atleastinoursocialdialogue,isconductsubjectivelymoreculpablethanerror. Negligence,asalegalterm,arisesfromboththecivil(tort)andcriminalliabilitysystems.

3.RecklessConduct
Recklessconduct,alternativelyreferredtoasgrossnegligence,Alsoalegalterm involvesahigherdegreeofculpabilitythannegligence. Recklessconductinboththecivilliabilityandcriminalsystems involvesconsciousdisregardofrisk.Recklessconductdiffersfromnegligentconductinintent; negligenceisthefailuretorecognizeariskthatshouldhavebeenrecognized,whilerecklessness isaconsciousdisregardofavisible,significantrisk.Considerthetermrecklessdriving.

4.IntentionalRuleViolations (alwaysforgoodreasons)
Mostrules,procedures,anddutieswillrequireorprohibitaspecificbehaviour. Theintentionalruleviolation occurswhenanindividualchoosestoknowingly violatearule whileheisperformingatask.Thisconceptisnotnecessarilyrelatedtorisktaking, butmerelyshowsthatanindividualknewoforintendedtoviolatearule,procedure,orduty

More Automatic

S R

Skill- based behaviour

Automated Routines with little conscious decision making or attention , eg riding a bike

Rule based behaviour

Following rules or procedures as packets of behaviour prompted by a sequence of instructions eg cooking to a recipe

More Conscious

Knowledge- based Behaviour

No routines or rules available. Situation only handled by conscious reasoning based on knowledgeable processing of factual inputs. eg driving through a strange city with the aid of a map and road signs
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ABCModelofUnderstandingBehaviour ActivatorsorMotivators
Whatprecedesorstimulatesorprompts..orcues

Activators

Behaviour

BehaviourorActions
Whatwedo.Whatweobserve.

Consequences

ConsequencesorOutcomes What
followsorresultsfromorisproduced by

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ABCModelofUnderstandingBehaviour
Activatorsormotivators
Whatprecedes orstimulates or prompts orcues
!attitudes,beliefs,skills,knowledge(orignorance),information processing, !goals,intentions,needs,expectations, !priorexperiences(consequences), !riskperception
! howmuchthepersonbelievesin being personallysusceptibletoagivenoutcome(ie.injuryor?); ! howmuchthepersonbelievestheconsequencesoroutcomesareserious; ! howmuchthepersonbelievesthatpreventativeactionisreasonable,practical,effective.

Activators

Behaviour

!temporarymental/physical/emotionalstates, !environmentalfactors(Bradley,1989):
*thephysicalenvironment

(ie.geography,architecture,aesthetics,climate,technology,tools,equipment,plant,etc.) *thetaskenvironment
(ie.activitiesperformed,variety,meaningfulness)

*theorganisationalenvironment

Consequences

(ie.systemsorrulesandregulations,policiesandprocedures,normsandroles);

*thepsychosocialenvironment
(ie.thebehaviour,attitudes,moodsofotherpeoplepresentintheimmediatesituation).

Averystrongpsychosocialinfluenceonbehaviouristhatofgroupnorms. ( peerpressure,socialpressure)

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ABCModelofUnderstandingBehaviour

riskperception howmuchthepersonbelieves Activatorsormotivators

!in being personallysusceptibletoagivenoutcome(ie.injuryor?); Whatprecedes orstimulates or ! thattheconsequencesoroutcomesareserious; prompts orcues ! thatpreventativeactionisreasonable,practical,effective. !attitudes,beliefs,skills,knowledge(orignorance),information Activators
processing, !goals,intentions,needs,expectations, !priorexperiences(consequences), !riskperception

Behaviour

! howmuchthepersonbelievesin being personallysusceptibletoagivenoutcome(ie.injuryor?); ! howmuchthepersonbelievestheconsequencesoroutcomesareserious; ! howmuchthepersonbelievesthatpreventativeactionisreasonable,practical,effective.

!temporarymental/physical/emotionalstates, !environmentalfactors(Bradley,1989):
*thephysicalenvironment

(ie.geography,architecture,aesthetics,climate,technology,tools,equipment,plant,etc.) *thetaskenvironment
(ie.activitiesperformed,variety,meaningfulness)

*theorganisationalenvironment

Consequences

(ie.systemsorrulesandregulations,policiesandprocedures,normsandroles);

*thepsychosocialenvironment
(ie.thebehaviour,attitudes,moodsofotherpeoplepresentintheimmediatesituation).

Averystrongpsychosocialinfluenceonbehaviouristhatofgroupnorms. ( peerpressure,socialpressure)

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ABCModelofUnderstandingBehaviour
Activatorsormotivators !priorexperiences(consequences)

Activators

Whatprecedes orstimulates or prompts orcues

!attitudes,beliefs,skills,knowledge(orignorance),information processing, !goals,intentions,needs,expectations, !priorexperiences(consequences), !riskperception
! howmuchthepersonbelievesin being personallysusceptibletoagivenoutcome(ie.injuryor?); ! howmuchthepersonbelievestheconsequencesoroutcomesareserious; ! howmuchthepersonbelievesthatpreventativeactionisreasonable,practical,effective.

Behaviour

!temporarymental/physical/emotionalstates, !environmentalfactors(Bradley,1989):
*thephysicalenvironment

(ie.geography,architecture,aesthetics,climate,technology,tools,equipment,plant,etc.) *thetaskenvironment
(ie.activitiesperformed,variety,meaningfulness)

*theorganisationalenvironment

Consequences

(ie.systemsorrulesandregulations,policiesandprocedures,normsandroles);

*thepsychosocialenvironment
(ie.thebehaviour,attitudes,moodsofotherpeoplepresentintheimmediatesituation).

Averystrongpsychosocialinfluenceonbehaviouristhatofgroupnorms. ( peerpressure,socialpressure)

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ABCModelofUnderstandingBehaviour
ConsequencesorOutcomes

Activators

Whatfollowsorresultsfrom orisproducedby
! realorperceivedchanges,increasesordecreasesin comfort/discomfort,ease/effort,simplicity/complexity praise/criticism/apathy, peergroupapproval/acceptance/ rejection risksofinjury/illness,risksofasset/propertydamage productivity,efficiency monetary/inkindincentives,piecerates satisfaction/dissatisfactionfordoingjobwell/badly discipline/punishment qualityandquantityofinformationfeedback

Consequencescaninclude:

Behaviour

Consequencescanoriginatefrom
internalsources (eg.self assessment,selffulfilment,selfappraisal) or,morecommonly, externalsources (fromotherpeopleandthephysicalenvironment)

Consequences

TheReinforcementinfluence ofanyconsequencedependsonthree factors : Value,Immediacyand Frequency of theConsequences Value Immediacy Frequency +OR eg praise,comfort,ease,approval,efficiency,money soonerORlatereg immediateordelayed often/frequent/certain/consistent ORinfrequent/uncertain/inconsistent

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ABC ModelofUnderstandingBehaviour Exercise AConfinedSpaceProcedure

Activators
*Hehasneverbeeninjuredbefore *OthersintheTeamdontuseCSP *Generalmachorisktakingculture *CSPEquipmentnotavailable *Dontknowhow/noskilltodoCSP PreviousConsequence? Yes/No? Yes/No? Yes/No? Yes/No? Yes/No?

Behaviour

SSP=OperatorNOTusingthe CONFINEDSPACEPROCEDURE
TypicalIncidentInvestigationFindings *Timeissaved/Jobdonefaster *Morecomfortablewithoutequipment *Nooneisinjured *TeamLeaderignoredwhathesaw *Noreprimand *Otherteammemberslikedspeed *RiskofDeathmuchhigher *Realisesheneedsskill/knowledge *Caught/trappedfor10minutes *Toxicgasdetectedafterentry
Value+/ Immediacy Frequency

Consequences

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GOOFUpsarealways partofcausationofrealincidents andpartofrisksofprobablewhatifincidents. GOOFUpsoccurwhenwedontdowhatweare: ! Supposed todo ! Should havedone ! Could havedone ! Wanted todo ! Tried todo ! Needed todo ! Told todo ! Expected todo ! Obliged todo ! Trained todo copyright 2009 risk@workplaces pty ltd

QRA.27

GOOFUpscanbeeither: ! intentional (substandardpractices,unsafeacts,atrisk behaviours,violations/breachesofrulesOR ! unintentional (errors,mistakes,nochoiceorintentand sometimesnoteventawareofthecorrect behaviour). Human Errors often defined as the goof-ups where there was no choice or intent
copyright 2009 risk@workplaces pty ltd

QRA.27

ALL safetydiscussions " safetymeetingsofanykind " postincidentdecisionmaking " employeecounselling " observationbasedinteractions " workmethoddiscussions shouldinvolveriskassessmentstoachieve ! alignedriskperceptions ! employeeownedprocedures
copyright 2009 risk@workplaces pty ltd