We build and maintain defenses that mitigate or Identify a recent eliminate error-likely conditions. In the end, near miss or event situations become predictable, manageable, Defend and brainstorm and often preventable. against improved defenses. Processes and systems are designed so that mishaps inevitable human errors become inconsequential. Affected employees need to be involved in designing the processes and systems. We are encouraged to report and discuss events and unsafe working conditions. We learn from these and make changes to lessen the likelihood of future occurrences. It is critical to involve the people affected by the event in identifying needed changes. Discuss whether these Questions to ask about an event are: are the right questions Is everyone okay? Report to ask about an event. Is the workspace safe for people to be If not, what questions in? would be better? Tell me your story…what happened? Tell me where else this same event might happen. Tell me how we can make this situation better. The Forest Service promotes an error-tolerant work Discuss what it means environment. to be an error-tolerant organization. The reaction to events by our leaders shows us if they the They do not criticize us when “walk talk.” we speak up about an unsafe situation, so we Tolerate How can you influence errors continue to report them, and continue to improve the leaders in your unit our reporting. Leaders help us learn from events, to change from and make needed changes, rather than and to “shaming “shame blame” and us. being a learning blaming” organization? Accident investigations need to consider “latent factors.” ATTACHMENT 10
Defend against mishaps We build and maintain defenses that mitigate or eliminate error-likely conditions. In the end, situations become predictable, manageable, and often preventable. Processes and systems are designed so that inevitable human errors become inconsequential. Affected employees need to be involved in designing the processes and systems. Identify a recent near miss or event and brainstorm improved defenses. Report We are encouraged to report and discuss events and unsafe working conditions. We learn from these and make changes to lessen the likelihood of future occurrences. It is critical to involve the people affected by the event in identifying needed changes. Questions to ask about an event are: Is everyone okay? Is the workspace safe for people to be in? Tell me your story…what happened? Tell me where else this same event might happen. Tell me how we can make this situation better. Discuss whether these are the right questions to ask about an event. If not, what questions would be better? Tolerate errors The Forest Service promotes an error-tolerant work environment. The reaction to events by our leaders shows us if they “walk the talk.” They do not criticize us when we speak up about an unsafe situation, so we continue to report them, and continue to improve our reporting. Leaders help us learn from events, and make needed changes, rather than “shaming and blaming” us. Accident investigations need to consider “latent factors.” Discuss what it means to be an error-tolerant organization. How can you influence the leaders in your unit to change from “shame and blame” to being a learning organization? ATTACHMENT 10
FinalSLP7SafetyTeamReport10_25_10.docx