WHAT IS 99% SAFE ?

To Err Is Human - English poet Alexander Pope, An Essay on Criticism, 1711

?If the nature of humans is to experience errors, slips, lapses and violations then the processes they operate/control/manage will have a failure.

?So, it would seem the goal is to have as error-free an operation as possible.? You may think 99% Safe is exceptional.? But what does 99% Safe Mean?

• ?100,000 Flights With Fatality (in U.S. for 1 Year)
• 1 Carrier Landing Crash Each Day
• 800,000 Bbls Of Oil Lost (1 Year 93 Million Bbls)
• Nuclear Radiation Release Kills 1000 / 5 Years
• 107 Incorrect Medical Procedures Each Day
• 12 Babies Given To Wrong Parents Every Day
• 291 Pacemaker Operations Performed Incorrectly
• 44,230 Incorrect Drug Prescriptions Each Week

That doesn’t seem acceptable. A lot of incident investigation reports tend to blame the human (worker) for the incident.? And, while some human error can be found, a true root cause analysis will find that the human (worker) was attempting to complete the task within a system that worked against them.?

?If an organization seeks better than 99% Safety (Goal Zero) then it needs to understand that people are operating a system handed to them by the organization.? A system that may have flaws or deficiencies.? Human error is a symptom or consequence of a flawed or deficient system rather than a cause for a failure.

?Consider an Aircraft Carrier wherein 99% Safe operations would mean up to one crash landing each day.? And look at the environment that the crewmen must operate in:

• Operations the size of San Francisco Airport into one short runway and one ramp
• Planes land & takeoff in same area in very short intervals
• The runway rocks from side to side
• Flight deck is wet with sea water & oil
• Equipment & planes right on edge of operational area
• Fueling planes with engines running while other planes launching/landing
• Manning the whole operation with young 20-year-olds – most new to planes

?The environment will foster the potential for human error.? And yet, the Navy can operate these complex machines without having a serous aircraft mishap through a whole tour.? A top performing organization employs a systems approach that recognizes the potential for failure can exist at any time.? They are constantly monitoring the operation for potential failures and are proactive in preventing them from leading to a significant event.

?Employing a systems approach, the organization needs to have clearly defined goals, and expected levels of performance.? All persons in the organization understand them and own them.

?The organization should expect variability in human performance, but maintain a constant mindset of vigilance, that is train people to recognize weak signals of potential errors or failure and act in advance of significant failure.? Be preoccupied with the possibility of failure such that you are continuously searching for system improvements.

A systems approach understands that employees work in an environment that needs defenses from human error. Organizations achieving Goal Zero are those that proactively seek to strengthen defenses and to quickly act when an adverse event occurs.

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