Reliability 4 Life

168 years ago in systems reliability (23 MAR 1857) Elisha Otis installed the first safety elevator for passenger service in the EV Haughwout & Co department store. Otis had demonstrated the safety elevator four years earlier in New York's Crystal Palace. (See inset left.) He cut the rope .... and the elevator stayed put. Otis did not invent the elevator - he invented the elevator safety brake. Elevators were notoriously unreliable. Most people took the stairs to avoid an elevator. If the rope or cable broke, the elevator would crash to the bottom. The safety brake made the system more reliable through increased resilience. Resilient is Latin meaning "to bounce back." The more resilient system can withstand a failure of rope or cable without failing the system. Otis became famous for making an existing system safe. Similar innovations gave us the safety pin, safety razor, and safety bicycle. Systems thinking is too important to save for work. Use systems reliability where you work, live, learn, and play. Visit our Reliability4Life website to learn how. #safety #highreliability #hro #safetyleadership

6 years ago in human reliability (12 MAR 2019) a mom left her child at the departure gate. The mom, flying Saudia from Jeddah SAU to Kuala Lumpur MYS, boarded her flight without the child. (See inset stock photo.) When advised of the problem, the captain exclaimed to controllers "May God be with us. Can we come back or what?" The flight returned to their gate, and mom and child were reunited. Imagine the anxiety of mom and child - and the captain, crew, agents, and other passengers. Human reliability is too good to save for high-consequence work systems. Use Life Skills where you work, live, learn, and play. Self-checking and cross-checking could have helped here. And, learn error wisdom - how well meaning people experience human error. How many of us judged this mom in the moment? How could she? Bad mom. How could a mom forget her child while boarding? Error wisdom (a good first read, Beyond the organisational accident: the need for "error wisdom" on the frontline by James Reason, 2004) is us as safety leaders understanding factors (task, context, and self) making human error more probable. Understanding enables us to access our own vulnerability. We can see that human error could happen to us, and seeing the possibility enables us to improve human reliability without judging / blaming the person. People do not fail. They either succeed or learn something. Use error wisdom to make your teams safe to learn something. #safety #highreliability #hro #safetyleadership

Today in safety science and high reliability (9 MAR 2025) starts Patient Safety Awareness Week in healthcare for 2025. Every day is patient safety day. Patient Safety Awareness Week brings added attention to keeping patients safe during hospital and clinic care - and where they work, live, learn, and play. Patient Safety Awareness Week also includes added attention to workforce safety (keeping safe the caregivers, providers, and support team members). This year's theme (as established by IHI) is Awareness, Assessment, and Action. And while the intent of IHI is to focus this awareness, assessment, and action on Safety Management Systems, everyone can apply awareness, assessment, and action to their daily tasks. This is the Mica Endsley model of situational awareness - perception, comprehension, and projection leading to action. See the harm and injury frequencies below. In the US, there is one patient death from harm every 2 minutes and 6 seconds. That is 251,000 patient deaths per year. In US healthcare, there is one workforce death every 66 hours. That is 133 workforce deaths per year. Share these insights this week. Act on these insights this week. Safety - don't just talk about it, be about it. #safety #highreliability #hro #safetyleadership

248 years ago in reliability (6 FEB 1777) General George Washington wrote a letter to his medical officer, Dr William Shippen, mandating smallpox inoculations for all soldiers in his army. This was the first medical mandate in world history. Washington was concerned smallpox among his small force of 10,000 troops would lose the revolutionary war for us. In those days, more troops died of illness than were killed in action. All were inoculated, and historians cite the mandate as one success factor in winning the war. Many of the continental troops were from rural areas where smallpox was less prevalent. Most of the British troops had already had smallpox. Mortality at the time was 50% for children and 10% for adults. Inoculation was already 50 years old at that time and done by introducing the virus under the skin with a scalpel. High Reliability Organizations (HROs) achieve high reliability through work systems. HROs manage system reliability using Prevent, Detect, and Correct (PDC) approaches. (Healthcare more often says Prevent, Identify, and Redesign (PIR).) Use safety culture and high reliability organizing practices to prevent human error / equipment malfunctions that lead to loss events. Detect latent conditions in the system(s) that allow human error / equipment malfunction to progress to loss events using monitoring and trending. And, Correct those latent conditions using learning systems. PDC (or PIR) is best deployed through Safety Management Systems (SMS). General George Washington understood the value of Prevention. Wisdom says an ounce of prevention is worth a pound of cure. Children's healthcare would say 0.0283 kg of prevention is worth 0.454 kg of cure. Be like George. Focus on prevention using a Safety Management System. #safety #highreliability #hro #safetyleadership

Two years ago in the world of reliability (26 JAN 2023) Kingsley Burnett of New York NY arrived his vacation destination 16 hours early. That was a red flag for Burnett. He had planned a winter vacation to Australia. Instead, he booked a ticket on American Airlines from New York (LGA) to Sidney MT USA. The airport code for Sidney MT is SDY, and the code for Sydney NSW AUS is SYD. Burnett knew something was amiss when he connected through Billings MT (that should have been another red flag) and was asked to board a small plane with only 9 passengers. How could such a small plane fly all the way to Australia? He did not connect to Sidney MT. American could not easily reroute Burnett to Australia, so Burnett returned to New York to try again in June. When life gives us setbacks - reliability gives us bounce backs. Human reliability is too good to save for work. Use #lifeskills where you work, live, learn, and play. Practice human reliability in all life spaces and at all ages. Learn and practice #lifeskills as a child, a teen, an adult, and an adult professional. The skills Kingsley Burnett needed to arrive Sydney NSW AUS, the skills of self-checking and questioning attitude, are the same skills everyone needs everywhere. Read more about #lifeskills on our R4L website (link in the comments). #safety #highreliability #hro #safetyleadership

Today in the world of reliability (20 JAN 2025) all workforce safety records are back to zero. Workforce safety data tend to run year-to-year, so our 2025 record is zero injury until JAN data becomes available in FEB. Our DEC 2024 data will soon be shared, as safety professionals tally the number of injuries and accountants total the numbers of hours worked. These data are then reported to OSHA on form 300A. With the new year - please take a look at your 2024 workforce safety results. Compare to benchmarks. Acknowledge any good progress in reducing injury. Analyze for opportunities in the next cycle of improvement. To simplify for our learning community, here are Bureau of Labor Statistics (BLS) benchmarks for healthcare. These are CY2023 results published in NOV 2024. Ambulatory (NAICS 621) TCIR = 2.2 DART = 0.9 Acute (NAICS 622) TCIR = 5.2 DART = 2.3 Post-Acute (NAICS 623) TCIR = 6.4 DART = 4.5 Home Health (NAICS 6216) TCIR = 2.0 DART = 1.3 Maya Angelou wrote, "Do the best you can until you know better. Then when you know better, do better." If you are above benchmark, you now know better - so do better. #safety #highreliability #hro #safetyleadership

2 years ago in the world of reliability (7 JAN 2023) Jesse O'Dell of Tulsa OK (inset right) tipped his Starbucks barista $4,444.44 - without knowing it. He bought only two coffees for $11.83. DeeDee O'Dell (inset left) learned of his tip when her credit card was declined while shopping. Ouch. Did Jesse O'Dell experience the fat finger error when entering his tip? No. O'Dell chose the no tip option. Starbucks later reimbursed the tip to the O'Dell's and explained a system error had caused the problem. All situational awareness starts with perception. Look. Then, think if that makes sense. (Situational awareness then finishes with projection - but that is for another story). Human reliability is too good to save just for work in high consequence industry. Use human reliability where you work, live, learn, and play. When real life gives us set-backs - human reliability gives us bounce-backs. #highreliability #hro #derisking #safetyleadership

For those who follow Craig Clapper PE and read his Today in Safety History posts, his collected posts for 2024 are now posted to our knowledge hub. You can download 2024 and previous year's. No need to sign-up, register, or even give your email address. Just use reliability skills where you work, live, learn, and play.

6 years ago in the world of reliability (26 NOV 2016) Christmas came early in Houston TX. A Bank of America ATM dispensed $100 bills instead of $10 bills. People being people, a long and unruly line quickly formed. Harris County sheriff's deputies arrived to stop the loss event. Bank of America did not disclose how much money was lost but did allow customers to keep the money they already had. The system causes of this loss event were attributed to a vendor error without details of proximate causes or system causes. Human reliability is too important to save for high-risk industry. Everyone should practice human reliability where they work, live, learn, and play. (When hundreds are loaded instead of tens, there must be a self-checking story in there somewhere.) Read more about preventing these loss events on our Reliability 4 Life website. See the link in comments. #highreliability #hro #derisking #safetyleadership

64 years ago in the world of reliability (18 SEP 1960) General Motors introduced the Chevrolet Corvair. Five years later consumer advocate Ralph Nader called the car "unsafe at any speed." The Corvair may not have been as dangerous as Nader claimed. There were latent weaknesses - a swing axle suspension, no sway bar on the rear, and lower tire pressure requirements on the front tires and higher on the back tires when virtually all other cars had equal tire pressure all around. But NHTSA testing in 1971 found the Corvair handled as well as other similar cars - cars like the Volkswagen Beetle. That was the problem. The Corvair handled like a VW Beetle and was marketed to drivers as a Corvette for the middle-class. When people drove the Corvair like a Beetle - the car was safe. When people drove the Corvair like a Corvette, they were the ones who rolled-up axles or rolled-over or spun-out. No car is so safe that the car can be operated unsafely. No task on the job is so safe that it can be done unsafely. No activity in life is so safe that it can be done unsafely. That is why Reliability 4 Life teaches #lifeskills to all people for all life spaces. Safety and high reliability are too important to save for the workplace. Use safety in all life spaces - where you work, live, learn, and play. #safety #highreliability #hro #lifeskills #safetyleadership