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Training to Reduce Human-Error Accidents

This article accompanies BP's Bubbling Cauldron

Tuesday, March 1, 2011
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When it comes to so-called "high-reliability" industries such as oil and gas production, aviation, railroads and even healthcare -- where mistakes can be fatal as well as economically and environmentally devastating -- making safety a top priority is good business.

In particular, it's instructive to look to the aviation industry, which has focused intensely on analyzing accidents to learn how human error, mechanical failures and unforeseen circumstances impact a catastrophe. 

In the last 25 years or so, crew-resource management has come to the forefront as an ongoing training and monitoring process to help workers approach their jobs as part of a team rather than as individuals.

The most famous recent example of the efficacy of such training was when US Airways Flight 1549 piloted by Capt. Chelsey B. Sullenberger made an emergency landing on the Hudson River on Jan. 15, 2009. No one was injured and all reports say the crew were highly trained and professional.

Essentially, CRM makes more efficient use of the assets people provide to the team -- technical proficiency, personal experience and observations, knowledge of equipment or conditions, and understanding of federal rules or company procedures -- to prevent errors or lessen their impact.

Calculating the impact of such training can be difficult, but it's something researchers from Texas A&M University, Rice University and ACT's Workforce Development Division have tackled in a paper, "Introducing a Subject Matter Expert-Based Utility Analysis Approach to Assessing the Utility of Organizational Interventions Such as Crew Resource Management Training," to be published in April's International Journal of Aviation Psychology.

"We found that CRM training in the airline industry results in [savings] of between $293 million and $177 billion," says co-author Tobin Kyte. "Thus, even under the worst, most conservative assumptions, it would seem that there would still be clear monetary benefits to the commercial airline industry from implementing CRM training."

CRM addresses all the foundational skills identified by the U.S. Department of Labor for the oil and gas-production industry: teamwork, planning and organizing, listening, leadership, problem solving and decision-making, and safety awareness.

"Either you hire to get those skills, or you train. You should probably do both," says Kyte, senior research associate with ACT, the Iowa City, Iowa-based company that provides workforce training in addition to high-school ACT college-proficiency exams.

Managers have a key role to play when a crisis strikes, says Rhona Flin, a professor of applied psychology at the University of Aberdeen's Industrial Psychology Research Center, who has been studying North Sea offshore oil safety since 1987.

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She says the fundamental skill sought in incident commanders across high-risk professions is the ability to make decisions under pressure and to provide leadership to ensure the crew members know how to perform their roles. The goal is to avoid confusion and chaos among the crew.

She recommends managers get psychological assessments to determine if they have the requisite crisis-management skills, provide them training to develop the ones they are missing or aren't experienced in, and let them practice, through some kind of simulation, making difficult decisions in ambiguous, high-risk, time-pressured situations.

"[Standard crisis-management] training is normally conducted in simulators and simulated scenarios in offshore sites. They are schooled in the most likely problems, such as fires, explosions, helicopter and boat crashes," she says. "However, major incidents usually have unforeseen combinations of problems or failures, and that is why it is important to have command managers who can quickly assess situations and make timely and accurate decisions."

A lesson from the Deepwater Horizon rig catastrophe is for companies to look at its near-miss situations that could have led to accidents and build scenarios from them and institute procedures that can help prevent or minimize the impact.

And that's important, says Kyte, in industries where, "if you make a mistake, there are huge consequences. If I make a mistake here at my job, the worst that can happen is I get a paper cut. This is serious, there are environmental issues ... [and there can also be] deadly accidents."

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