SAFETY
Transport Canada, we have the “Dirty Dozen.” If you train people to recognize these and teach how to avoid becoming prey to them, it should reduce errors made. The diffi culty is in seeing the opportunities for error coming and knowing that for every Dirty Dozen factor, there are deeper causes that we do not often address. This is because root causes are usually buried in human nature. You can’t just put up a “Dirty Dozen” poster and think, “OK, all we have to do is NOT fall prey to any of these things” and expect that to happen. Knowing that you feel like you are being rushed doesn’t in any way off er relief from feeling that way. It’s one thing to talk about not working through fatigue but quite another for a supervisor to say, “We’re all tired — let’s go home early and come in late tomorrow because we’ve worked 10 hours a day for the last three days,” or for you to say, “Sorry boss, I’ve been here for eight hours and am too tired to get in the truck and fi x a broken machine in the fi eld.” Even if we did do these things, we are often fatigued not because of how long we worked on the job but because of what we do outside of work. The real issue might be how long a commute someone has or whether or not they are getting enough sleep. We might skip the written documentation not because we are lazy but because we honestly think we know what it says. We never imagine when distracted that it will end with, “Where did I put that tool?” We don’t know we forgot something BECAUSE WE FORGOT IT! I once worked with a pilot who lit off the engine in his Jet Ranger with the blades tied down. He never wanted to do that again, so he put a white sock on his cyclic stick post fl ight so it would remind him to untie the blades if he hadn’t done so. This worked for him for a while, and then he did it again, with the sock in place. A good pre-fl ight using a checklist is what he really needed to do.
THE SIX EMOTIONAL STATES We use the “Dirty Dozen” as convenient labels for what causes errors, but I think what is behind these labels is where we need to be looking. You probably know of the “seven deadly sins” which are pride, envy, anger, greed, laziness, gluttony and lust. I’m going to borrow them out of context and drop gluttony, lust, anger and greed for this discussion, but I’ll add forgetfulness, deceit and fear. Instead of the seven deadly sins we now have the
six sometimes-good, sometimes-bad emotional states: pride, envy, laziness, fear, deceit and forgetfulness. We can control these pretty well except for forgetfulness. In my mind, these are the root causes behind the “Dirty Dozen.” They are the things that allow us to make the choices such as, “I can skip that step in the procedure,” or, “No time for the written checklist, I know it by heart.” The weird part is that some of these can strengthen our ability to produce a safe product or they can work against us. You can be proud of your work (good) or you can have false pride (bad) and think your work is better than it really is.
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