Psychology of Safe DP Operation

Perils of Perfection:?I once followed another speaker and was surprised to hear him talk about “zero incident DP operation”.?I had either never heard or never noticed the phrase before and had an immediate instinctual dislike to it.?Alarm bells went off in my head and my instincts led me to warn against it before beginning my presentation.?I didn’t mean to insult or undermine him by warning against it.?He meant well and was expressing a goal, but I thought it was an unattainable goal and thought there was the danger of people thinking that we could achieve it.

My primary reason was safe operation itself.?When people think they are safe, they take more chances and become less safe.?Safe DP operation is more dependent on attitudes than it is on technology and management systems.?People have a natural level of acceptable risk and if they think they are safe then they are willing to take unreasonable risks and shortcuts.?People, who think they are at risk, strive to improve and maintain safety.?We all have technology, procedures, and corporate culture, but how they are used is important.

In the end, it comes down to people.?People design, install, maintain, and operate the technology, and people are deeply integrated into the operation of every system.?That can be a good thing that props up poor systems and management, or a bad thing that negates excellent technology and procedures.?Industries often start propped up by excellent leadership, and when matured, suffer from unexpected failures despite a clearer understanding of the risks, better technology, and better systems.?Replacing leadership with management, and curiosity & concern with requirements, endangers safe operations.

The normalization of risk increases risk, and protective requirements can become the cause of problems.?The requirements are meant to keep everyone safe and, as they become increasingly onerous and distracting, they can become the focus of safety.?But they are not safety, they are tools to achieving it.?When the tools are more important than the task, safe operation is endangered and past success can be corrosive.?The tools are not the task and there will always be a misalignment of the two.

Reason is a wonderful tool, but it is double-edged and can be dangerous, unless grounded in deep understanding.?Have you ever seen a presentation by smart people who bypassed “unnecessary” safeties because the risk was low??We have seen them done by the lucky, but probably remember those who were unlucky better.?The risk was low but larger than they thought.?This is the path to major incidents.?Thought is hard but analysis is easy.?Justifying desired conclusions is simple but understanding is hard.

The more intelligent you are, the easier it is to make that mistake, while experience breeds caution.?There is a war between the two in every industry.?The need to get things done quickly and efficiently is balanced with the need to do it successfully and safely.?When things go wrong, standards are tightened, but over time, standards are slowly eroded, as they are costly and appear unnecessary, until a major incident restarts the whole process.

There are many examples in many industries but a simple example that I found instructive long ago is useful – “Don’t walk under a ladder.”?Why not??“It’s bad luck.”?That’s just superstition and real problem is that the ladder, equipment or a person might fall on you.?“No, it’s bad luck.”?It’s not luck.?It’s all probabilities and I can manage the risk by minimizing time under the ladder and crossing when I think it is safe.?“So, you’re taking a chance rather than just walking around?”?Yes, rational decision making, not superstition.?“You’d have been safer if you just walked around, but laziness increases the risk of getting hurt.?The odds of getting hurt increase because you’re taking an unnecessary chance.”?It’s manageable.?“No, it’s bad luck.?You think you can control the odds and sometimes you are right but sometime you are wrong and the odds of injury go up.?You can’t control luck, and can’t control the odds as much as you think you can, but you can make better choices.?The simple rule improves safety while analysis increases your chance of taking a risk.”?And that’s bad luck??“Usually.”?But sometimes you have to go under the ladder.?“Then realize that it’s a risk and take it seriously.?Once you stop taking it seriously, the bad luck will prove itself.”?There is something intuitively important about this.

The aircraft industry, nuclear industry, and NASA can’t achieve zero incident DP operation, so why would we think we could??No plan survives contact with the enemy and the enemy is us.?Worry about your DP system.?Worry about your maintenance, training, and operation.?Success climbs the wall of worry.

Success isn’t the absence of mistakes - that is impossible, nothing is perfect.?Infinite success requires infinite time, effort, and cost.?Real success is limiting the frequency and severity of failures to acceptable levels, at an acceptable cost, over many years, and learning from problems.?Short term efforts and success can lead to greater danger, and increased analysis and requirements can blind people to risk.?Experience tempers intelligence.?Investing in some worry and doubt can be healthy.