Do Safety Differently. Do the New View.
By Josh Welp, FNF Safety Director
Texas employees participate in a game of Jenga during the HPI safety training held at the Ward County Event Center in Monahans, TX . Every time a block is pulled from the stack, it creates other blocks to loosen or tighten in the stack. The missing blocks represent sources of variability which are latent organizational weaknesses leading to human error. HPI puts controls and defenses in place in order to fail safely and avoid human loss of control.
To err is human. Our senior leadership and field supervisors recently attended supervisor safety training where we spent considerable time discussing a new concept called Human Performance Improvement (HPI). HPI is an operating philosophy designed to systematically protect people, property and equipment from human error. Human error and variability are pervasive in our every-day work so it is crucial for us to have controls in place that manage and mitigate our risk. If not, a loss of control could lead to unwanted outcomes. Having capacity, which is defined as having the ability to flex, bend, fail and recover, is essential to our resiliency and sending our people home safely to their families. While human error is normal and universal, it is never causal or a choice. Implementing the new view of safety will improve our safety culture.
The 5 Principles of HPI, which serve as building blocks, were introduced to the attendees and they include: 1. People make mistakes; 2. Blame fixes nothing; 3. Systems and context influence behavior; 4. Learning and improving is vital; 5. How we respond to failure matters. Practicing these 5 Principles and continuously improving our safety and health management system helps create reliability and resiliency at FNF. To illustrate an event that failed to follow the 5 Principles of HPI as guidance involves a nurse making a human error at Seattle Children’s Hospital. The critical care nurse had worked 24 years at this institution and this was her first medical mistake. She was working with a 8-month-old baby that was born with severe heart problems. While the baby’s nutritionist was talking (distracting) to the nurse as she was giving calcium chloride for normal cardiac function, the nurse administered 1.4 grams instead of the recommended 140 milligram dose (10 times stronger) through the baby’s IV. The nurse experienced a slip and lapse that all humans have. The baby died five days later due to heart failure. As a result, the nurse was escorted from the hospital after the mistake, immediately put on administrative leave, fired within weeks, and finally lost her license. The nurse soon became the second victim as she dealt with depression, anxiety attacks, and sleep disorders. Seven months later, she hanged herself in the family’s basement. To summarize this event in the old view, the nurse made a mistake; she was fired with a clean record; the hospital sent the message (context) to nurses and doctors, if you make a mistake, you better keep your mouth shut; learning and improvement did not take place as the system was not modified; and the hospital’s response sent a message of fear and retribution. I do not know of any nurses who do not care about their patients. They want to help and love people. Unfortunately, this hospital and others demand perfection every time, which is impossible. Instead, a system needs to be created that has controls in place to accommodate human error.
Practicing the new view of safety is encouraged, as we want to build a safe, reliable system that has the capacity to fail safely knowing that people are the solution, not the problem. Our employees will continue to make mistakes so do not find blame, but rather, fix the system and create context that positively influences worker behavior. Exercising the new view will help send our employees home safely to their families and this is a win-win for everyone.
Josh Welp, CSP, CHST, CRIS
FNF Safety Manager
Josh joined FNF in 2018, bringing more than 20 years of experience in construction safety. He holds a Master’s degree in Safety, Health and Environmental Management, is a certified OSHA trainer, and holds a number of professional certifications.
Josh has both field and program management expertise from his prior positions as a safety professional in the construction industry. Earlier in his career, he spent 4 years as a Compliance Officer at ADOSH (Arizona Division of Occupational Safety and Health), which adds to his perspective from the compliance side.