Cable car accident

There has been an accident on the Nevis Range cable car system in Scotland. See article at http://news.bbc.co.uk/1/hi/scotland/highlands_and_islands/5178870.stm

We had a great day out on this last summer when we were touring the area. It was our younger son's birthday treat, before going to MacDonalds in Fort William for lunch (his idea, not ours).

It will be interesting to see what the cause comes out to be. More immediately, how to you balance risks with having a good time. Of course there must be risks from cable cars, but people seem to expect that everything can be made risk free. We have a cable car system in Llandudno, but it has not worked for several years (I don't know why). I doubt this accident will help its restart.

Radiation risks

There was a very interesting edition of Horizon on BBC2 last night. See write-up here http://news.bbc.co.uk/1/hi/sci/tech/5173310.stm

Looking at data from Chernobyl, the cases of cancer following the accident are far lower than expected. The suggested reason is that the predictions were based on data from the Hiroshima and Nagasaki nuclear bombs. Whilst these provided plenty of data for high doses of radiation, the effect of low doses was determined on a straight line graph, suggesting all levels of radiation have some risk. The basic premise of the Horizon program was that there is a minimum threshold, below which there is very little risk and in fact some data suggests it may be beneficial.

I had always naively assumed that when it was reported that 2,000 or 20,000 people had died prematurely as the result of Chernobyl, that this was based on medical data (i.e. the actual number of people that have died). It actually turns out that this was probably based on projected figures. A good example of where a projected figure is published, and over time it starts to be quoted as an actual result.

I have often wondered if we can get useful data from animals. They were not evacuated from region after the accident, and even today there are sheep in the UK that are considered too contaminated for human consumption. The program did follow this line of investigation, and claimed that there was no evidence that animalimal populations were suffering from the effects.

ossibly more harmful than the actual exposure.

Emails deleted from server

Apparently PlusNet have wiped a load of emails from their server during a system upgrade. It is estimated 700 GB of data was lost when a a senior engineer mistook the management interface of a live email server for that of a backup server, and erased all the data on the wrong one.

Company representative Ian Wild has assured disgruntled members: "It was a genuine mistake, an accident, and I'm afraid no measure of change control procedures or anything else would have completely prevented this. At the end of the day, all we can do is hold our hands up here and say that although an unfortunate set of events, this should never have happened… you can never remove the risk of a human error entirely."

Interesting how companies start to say human error cannot be totally eliminated when they think it might get them out of paying compensation. Conversely, they choose to blame individuals for making errors (i.e. suggesting errors are preventable) when they think that transfer the heat from the company. Or am I being cynical?

Article is at

http://news.zdnet.co.uk/communications/0,39020336,39278586,00.htm

Basic ergonomics

Although I am a registered member of the ergonomics society (virtually equivalent to being chartered - but the society does not yet have chartership available) I rarely get involved in what I call 'basic ergonomics.' To me this is the occupational health side, whereas I usually deal with major hazard risks and more interested in human error and system safety.

Found this useful summary of 'eight ergonomic essentials' at http://www.freelancenews.com/lifestyles/contentview.asp?c=189667&siteID=33

1. Move frequently - "the best position is the next position."
2. Rest frequently.
3. Use proper postures - maintain the spine's natural curve
4. Keep an eye on vision - make sure things are at or just below eye level and in front of you at a comfortable viewing distance
5. Organise things into your reach zone
6. Use the right tool for the task
7. Don't be afraid to ask for help
8. Listen to your sensible self - look at what you are doing and ask if things could be arranged better

Unable to use the emergency phone

Continuing my theme of problems caused by technology. Talking to some people recently. They have to communicate with an offshore platform. There was a problem with the 'land-line' phone system. Following previous problems, they had been provided with a satellite phone. Unfortunately they had never used it before, and were not sure how to use it. Also, they did not know what number to call to contact the platform.

People seem to assume new technology creates automatic improvement. This is clearly not the case.

Ship sinking - crew unable to use new technology

Article in Risk digest at http://catless.ncl.ac.uk/Risks/24.33.html summarises initial findings of inquiry into sinking of Queen of the North. Ship had a new computer based chart system. Crew did not know how to reduce the illumination level from the screen, which at night caused them problems. Their solution was to switch the display off.

Space probe error

According to an article at www.cnn.com on June 14 2006 and recreated in the risks digest at http://catless.ncl.ac.uk/Risks/24.33.html engineers made a catastrophic error when they put together the Genesis space probe. Apparently they put in gravity switches in backward. These were supposed to deploy a parachute as the probe returned to earth, but instead it crashed to earth and was destroyed. Also, the makers skipped a critical pre-launch test and simply did a paperwork review. It is claimed this was partly due to severe financial constraints caused by competitive tendering process.

Handling uncertainty

Interesting article in May 2006 Chemical Engineer by Chris Beale.

includes Donald Rumsfeld's famous quote "There are known knowns. These are things we know we know. There are known unknowns. That is to say, things we know that we don't know. But there also unknown unknowns. These are the things we don't know we don't know."

Chris points out that people often interpret risk assessment as certainties, when this often far from the case. He proposes three levels of uncertainty.
1. Using established technology. Minimal uncertainty.
2. Incremental change. Risks considered to be similar to those already known. Use management of change but recognise there may be incorrect assumptions about impact of change.
3. Step changes to completely new product or process. Need to pilot and then scale up. Expect to uncover many gaps in knowledge.

The suggested yard stick for assessments is to consider if you assessed the risk using worst case data, would it change your recommendations for risk reduction measures? If yes, uncertainty could be critical and a cautious approach is required.

Perceptions of management commitment to safety

I come across it very often that people at the sharp end perceive that their managers, although saying the right things, are not really that interested in safety.

An article in May 2006 Chemical Engineer by Tom Woollard illustrates this. "Most easy to spot is the company executive who makes sure that 'health and safety is the first agenda item' and is adept with emergency exit briefings and the 'safety first' and 'people are our greatest asset' rhetoric; and yet is often seen speeding out of the car park, sales figures on the passenger seat, clutching their mobiles to their ears. These kinds of safety observations tend to travel quickly through the organisation whether or not they are recorded in the safety log book."

Tom relates this to failures in behavioural safety programs. This occurs either through lack of commitment or perceived sincerity. Often because the company has not got the right culture in place for the program to work effectively.

One solution, apparently, is to make sure people understand the importance of safety at work and at home. This supposedly starts to work at an emotional level.

I guess this can work, but as Tom says it is easy for them to be seen as gimmicks if done badly. I guess my concern is that the message become that risk is not acceptable, and it can quickly result in people not doing what they enjoy doing when out of work.

Speed cameras

I drove past the spot at the weekend where I picked up a speeding ticket a couple of years ago. It is in Caernarfon, North West Wales. The ticket said I was doing 42 mph in a 30 limit

The problem I have with is that at the time I thought I was in a 40 limit. OK, so I was still over that limit, but by a much lesser margin. The road where the camera is located chops and changes limits, and I would argue there are few visual clues (other than the signs at the change points) to inform you what limit you are in.

So I got a ticket, not for speeding to great excess, but for not noticing a change in speed limit. I really wonder how effective it has been at changing my behaviour or attitude, and hence has there been any improvement in the safety of my driving? The only major change I am aware of is that I now know to drive at 30mph on that particular stretch of road. Something I may do a handful of times per year.

I think this has parallels with what we talk about in industrial safety and human factors. If we take actions at face value we may make interventions that either have minimal or counter-productive affects. If we have too many rules and/or enforce them too rigidly the culture will change completely. Equally, if we are too lenient there will be consequences. I guess there is a balance to make, and we have to work continuously to make sure that balance is being achieved.

Risk Aversion

Interesting article in RiskTec's quarterly newsletter Spring 06. See www.risktec.co.uk

There is great concern about risk aversion leading to crazy decisions. Reasons for this vary but fear of litigation, dogmatic implementation of policy without considering its suitability, belief that risk should be eliminated and simply using it as a conventient excuse are all noted.

A list of UK examples is provided

A 73 year old pensioner from Cardiff was ordered off a bus for carrying a tin of water-based emulsion paint.
Children at a London primary school have been banned from making daisy chains in case they pick up germs from the flowers.
Barmaids across Europe may be forced to cover up because of an EU directive on sun exposure.
A district council felled a line of conker trees to prevent youngsters from injuring themselves while gathering conkers.
A girl was banned from bringing sun cream into class during a heatwave in case it caused allergies in other pupils.
Two Christmases ago, a secondary school in Chipping Sodbury banned the wearing of tinsel to prevent any danger of strangulation.
Cakes baked by Radwinter WomenÂ’s Institute were banned from a hospital over fears they could present a health risk to elderly patients.
AA publicann from Taunton Deane was prevented from displaying hanging baskets on the front of the Ring of Bells pub by council officials concerned that some of the
flowers might spill onto the pavement, forcing pedestrians into the road.


Also, from www.landroverclub.net/Club/HTML/humour_silly_laws.htm and www.dumblaws.com

Alabama state law prohibits a driver to be blindfolded while operating a vehicle.
In New Britain, Connecticut, it is illegal for fire trucks to exceed 25mph, even when going to a fire.
It is illegal in Singapore to drive within 50 metres of a pedestrian crossing the street.
In Evanston, Illinois, it is unlawful to change clothes in an automobile with the curtains drawn, except in case of fire.
In Luxembourg you must have window wipers but you are not required to have a windscreen.
Danish law stipulates no one may start a car while someone is underneath the vehicle.
A driver in Belgium who needs to turn through oncoming traffic has the right of way unless he slows down or stops.
In Thailand, the law requires you to wear a shirt while driving a car.
And finally, although the underlying reasons are unclear, spare a thought for the Swiss, who are not permitted to wash their car on a Sunday.

Managing workplace transport risk

HSE have a proposed 'route map' out for consultation. It is important because 70 people were killed in accidents involving workplace transport in 2004/05

The route map is divided into four sections

1. Site layout and design
2. Vehicle selection and maintenance
3. Personnel matters
4. Management responsibilities

As it stands, my feeling is the document is weak and has a number of omissions. I think there is a fundamental problem because the causes of accidents is not made clear, so it not easy to see which of the proposed measures is likely to be most effective.

As with many things, my experience is that management of change is one of the most important elements, and it requires everyone working on a site to be aware of the risks of change. In particular new routes (including temporary and one-off), different vehicles, different activities and change to plant and equipment next to traffic routes can influence the risk.

I have sent some comments to HSE. You can do the same by going to
http://consultations.hse.gov.uk/inovem/consult.ti/wptms

Why most training doesn't work

Article in June 2006 Chemical Engineer about project management included a paragraph about why the 'obvious' answer for improving management is training, but that most proves to be ineffective.

It states that for an individual or team to improve they need to improve knowledge, attitudes, skills and habits. The vast majority of training concentrates on knowledge and skills. People may well gain these, but if they do not change their attitudes or habits there will be minimal affect. The problems are even worse if people do not think they need training (i.e. being sent on a mandatory course). Lack of confidence can also be an attitude problem that means people continue to avoid using the skill even after the training.

In my experience, most training is done 'on the job.' This has many benefits, but needs to planned, controlled and verified. Unfortunately planning, control and verification are usually only carried out for formal training events (e.g courses).

Good teams

Article in Appointments section of the Sunday Times on 4 June 2006.

Relating to football, with the World Cup on its way. "A team of champions doesn't make a champion team." From this the prediction is that smaller teams with reasonably well educated people who are highly driven by representing their country will do better (e.g. Croatia and Australia). Compare to bigger countries that often disappoint.

I find that the aging workforce is affecting team work in companies. Whereas there used to be a cross section of age and experience, this is no longer the case. In the past the young guys did the running around whilst the older ones could do the thinking. Now the middle agers are doing everything.

7 July 2005 - emergency plans

Final comments from the 7 July bombing response report. See previous posts.

The report suggests there was a lack of consideration of the individuals caught up in major or catastrophic incidents. Procedures tend to focus too much on incidents, rather than on individual and on processes rather than people. Emergency plans tend to cater for the needs of the emergency and other responding services, rather than explicitly addressing the needs and priorities of the people involved.

Part of the problem was that plans were developed in light of September 11th in New York where most people died and relatively few survived. This was opposite in London on July 7 when there were a great number of survivors to deal with. From this it was recommended that plans need to be recast on the needs of individuals involved in major catastrophes rather than the needs of emergency services. This will require a change of mindset from incidents to individuals and from processes to people.

7 July 2005 - technology

More from report of the 7 July bombing response report. See previous post.

Tim O’Toole, the Managing Director of London Underground is quoted in the report as saying a year before the event that “the big lesson for us is to invest in staff, rely on them; invest in technology but do not rely on it.”

I think this is an excellent insight. Equally it is interesting the report, having made this point, then talks at great length about having additional technology in preparation for such an event in the future. In particular, there were major problems with communication because mobile phone systems were overloaded and because emergency services could not communicate underground. I totally agree these were major weaknesses, but it seems likely that we need our emergency plans to work when technology is not available, and to use the technology when it is available to assist.

An interesting point is made about the ambulance service. They are now issuing key staff with pagers again. They had stopped doing this a couple of years ago because it appears that mobile phones do a better job. We are all starting to expect mobile phones to work reliably, but that can never be guaranteed with any technology.

7 July 2005 - emergency management

The report of the 7 July Review Committee has published it report examining how the multiple bombing in London were handled. It is available at http://news.bbc.co.uk/1/shared/bsp/hi/pdfs/05_06_06_london_bombing.pdf

It states that one of the main problems was establishing exactly what had happened. There was very little communication from underground, where three of the bombs exploded, and much of the initial information was conflicting. Even once it was established what had happened, establishing the scale of the incident was very difficult. This was partly due to a procedural failure where each emergency service declared their own emergencies at each scene, whereas the first declaration of an emergency should have applied to all the services.

This seems fairly typical in my experience of emergency management. There is a general reluctance to declare an emergency. Although people do tend to start following the emergency procedure, the lack of formal declaration often causes delay and confusion.

I also wonder if a single command centre for all the emergency services would have been more effective. There seems to be political problems with the emergency services working together, which are simply beyond me. We want a combined response, and them have seperate control centres does not seem to help in any way.

Isambard Kingdom Brunel

We have just returned from a week's holiday in Bristol. Given that it is 200 years since Brunel was born and his strong links with the city, there was a lot about him in the various museums we visited and at the SS Great Britain (the first large iron hulled steam powered ship).

An interesting point made about Brunel was that he was not always successful. This demonstrated he was willing to take risks and usually learnt from his mistakes. It is suggested that this is how he was able to push technology so far.

I am concerned that we are tending to become more risk averse, but when we finally decide to do something we expect to it to be successful and rarely look back to see if we made mistakes that we can learn from. Some of Brunel's failures cost people's lives and caused companies to go bankrupt, but surely we should know enough about risk management now to take calculated risks and know the warning signs that mean we stop an endeavour before actual harm is experienced.

Wikipedia on human factors

There is currently a discussion on www.Wikipedia.org about whether human factors and ergonomics should be merged into one topic. There is quite a difference of opinion. I think this is partly because the terms are used differently in different countries and settings.
The main question seems to be whether ergonomics is more focused on anthropometrics and human factors on cognitive and perceptual factors. Those who support the merge seem to suggest that both terms cover the whole subject. Those that oppose seem to suggest that there is a big overlap, but the different focus constitutes separate subjects.
To see the debate go to http://en.wikipedia.org/wiki/Talk:Human_factors

For those of you who don't know, Wikipedia is an online encyclopedia that is made up through informal collaboration. The idea being that anyone can add or edit, and over time the subjects will evolve to a consensus.

Safety photo .co.uk

Another good web site for basic health and safety

http://www.safetyphoto.co.uk/

Some useful risk assessment forms. Some of the jokes are good.

Health and safety for beginners

This looks like a great site for basic health and safety.

http://www.healthandsafetytips.co.uk/About_Us.htm

The downloads look particularly useful. The site is not-for-profit, which is very commendable. Well worth a look.

A classic case of human error

Article on BBC website about the nuclear accident at the Tokaimura processing plant in Japan.
http://news.bbc.co.uk/1/hi/sci/tech/461738.stm

Critical mass was achieved because the technicians put too much material in a container, and it happened to be more enriched than usual. An example of why you need to understand the types of errors that can occur and put appropriate measures in place.

Three categories of ergonomics

A useful overview of ergonomics appeared in an article reporting that Gavriel Salvendy from Purdue University has been internationally honored in the field of ergonomics by Ergonomia, an international journal.

It states:

"The field of ergonomics can be divided into three categories: physical, social and cognitive. The physical area deals with problems involving lifting, pushing and more specifically, with injuries associated with the workplace such as carpal tunnel syndrome. The social area concentrates on the design and composition of group dynamics and the interactions of people. The cognitive area focuses on designing computing systems that match human mental capabilities. These systems understand how humans perform certain tasks and emulates them through artificial intelligence."

Article source http://www.purdueexponent.com/index.php/module/Issue/action/Article/article_id/3935

Custom sign generator

Found this site. Can't quite think of a practical application at the moment, but could be a fun way of getting messages over. Allows you to add your own text to safety signs, monopoly cards, FBI badges etc.

http://www.customsigngenerator.com/

US Accidents

I have been looking at the US Chemical safety and investigation board's website. Some useful information including video summaries of recent accident investigations, including BP Houston. Well worth a look at:

http://www.csb.gov/index.cfm

Failure to take up technology changes

Two examples in the office where new technology doesn't quite work as intended.

Network printers seem like a great idea to me. You get a fast, good quality printer that may have additional features like double-sided printing. But people are used to having a printer on their desk, and perceive this to be better than having a network printer. So they either keep hold of their printer or obtain one. This throws the cost-benefit that was made for the change to networked printers. The company either has to stock the ink cartridges for the personal printers in stores, or the employee obtains them via expenses. Also, the company either has to continue providing support for the personal printers, or individuals spend their own time fiddling around.

On a similar note, the move to networks that can be controlled, backed-up etc. Again people perceive it is still better to keep some documents on their own hard drive. This is especially the case after there has been a network outage. Of course the problem is that the hard drives are not backed up. Also, copies start t be held and keeping track of version changes becomes impossible.

In both cases, failure to change behaviour means the technology change does not achieve what it was supposed to.

Daft safety rules

Our house has had a loft conversion, so it occupies 3 floors. Apparently building regulations require it to have self closures on all doors on all floors.

Now I can see the idea and understand it in a house spilt into bed sits or similar. But in a family home it must be much more dangerous. Not only is there the risk of trapping fingers, no family can live with doors closed all the time. So all that happens is that doors get propped or wedged open. This makes it far more difficult to close a door if a fire does occur.

Communication errors

Two jokes that illustrate how the spoken word can cause problems.

First - you have to say this one out loud. There were twenty sick sheep. One dies. How many are left? People will say 25 because they think you said 26 sheep.

Second - a bit saucy. A man was having problems in the bedroom department. His GP had done various tests and given him tablets, but no good. He had seen a psychiatrist, but they were at a loss of what the problem was. So he went to see a witch doctor. He said he had a solution, but it would only work once per year. To get it up he had to say 1-2-3. To get it down 1-2-3-4. That evening the man jumped into bed with his wife and said 1-2-3. His ask wife asks 'what's the 1-2-3-for?'

Checklist for change

Final piece from 'change management in a week.' see previous posts.

Initial concept
Ask:

• what change is required?
• what are we trying to achieve?
• what will be the benefits?
• what will be the costs?
• how long do we have to make the changes?
• what is the likelihood of success?
• what are the alternatives?
• what happens if we do nothing?

Watch out for

• do not get tunnel vision - focus on outcomes and weigh carefully the possible alternatives for achieving them
• do not underestimate obstacles.

Unfreezing

Ask

• What will be on the project team?
• who will be the change manager?
• what need to be done when?
• what are the likely obstacles at each stage?
• how will be create dissatisfaction with the current?
• how will we create a vision of the future?
• what will be the milestones to show progress?

Watch out for

• disguised resistance (people saying yes when they mean no, actions not matching words)
• don't underestimate the task
• do not underallocate resources
• watch the detail
• ensure a sense of urgency is created.

Moving

Ask

• what are the indicators that change is happening?
• are new ways of working/structure being adhered to?
• are the barriers being overcome?
• have significant dissenters been removed or neutralised?
• are people receiving sufficient support, coaching, training?
• do recognition and reward systems match what is being required by the change?

Watch out for

• verify changes are being made
• create and celebrate quick wins
• ensure managers communicate a consistent message (discuss differences of opinion in private)

Refreezing

Ask

• Is the recognition and reward system continuing to support the change?
• have news ways of working become part of the routine?
• has the change delivered the expected benefits?
• what needs to be changes next?

Watch out for

• check that people are not sliding back into old ways of working
• do not celebrate victory too early
• ensure that benefits are being delivered and communicated

Why change is resisted

More from "change management in a week."

There is lack of communication so that people do no

• understand what the change is
• understand what the change means
• understand why the change is necessary
• understand the urgency
• understand how it fits into the bigger picture

lack of will to change so that people do not

• want to change, they are comfortable with how things are
• believe change will deliver the results

Lack of acceptance of the change process because people

• do not like the way the change is being handled
• are not involved in the decision
• are not consulted
• do not like being told what to do
• thing they are being treated unfairly
• thing others are being treated unfairly

Lack of incentive because

• people do not see any personal advantage from the change
• people do not see improvements in their working terms or conditions

Perception that the new way will be worse because

• the job will become less interesting
• will have less autonomy or flexibility
• reduce social interaction
• break up existing team

Threats of change

• reducing power
• undermining position and status
• undermine personal development
• damage routes for promotion

Perception of change

More from 'change management in a week.' See previous post.

You can see why change that affects people has problems. Someone initiating a change may feel ' the change is only small, no one will lose their jobs and the new organisation will be much more efficient.' The people affected are more likely to think 'the change looks large, any efficiency gain must result in job loses, the work will be different and I am not sure I will like so much and I may not be working with my friends. Where will I be in the pecking order after the change?'

Those being affected are likely to have many unanswered questions. They go through the roller-coaster of denial (it is unnecessary and won't happen), blaming others for making it necessary, blaming themselves for not seeing it coming and getting out sooner, despair as there is nothing they can go, realising it won't go away, giving it a go (trial and error), gaining confidence and finally getting results. Management need to be aware and:

• be prepared and not surprised by the reaction;
• plan for a downturn in performance during transition;
• providing information and support;
• expecting anger and apparently irrational responses;
• conceding on points that do not fundamentally affect the change (giving way);
• helping people experiment with the new ways;
• Setting targets and goals as the situation becomes clear so that people can understand what success looks like.

Good example of different perceptions. Scientist would describe water as a clear, odourless drinkable liquid. People lving next to a polluted river would see it differently.

Change management

I have been reading "Change management in a week" by Mike Bourne and Pippa Bourne under the Chartered Management Institute. I found it quite a good, brief guide to the issues of change management. The "in a week" format is pretty pointless, but never mind.

The book points out that you can take a 'hard' systems view of change by asking:

• What is the problem?
• What are the alternatives?
• Which alternative gives the best solution?

But that this does not overcome the 'soft' aspects of change, which are the reasons why most changes fail.

Some changes are 'harder category whilst others are softer. For hard changes timescales are clearly defined and relatively short, resources and objectives are clearlyn identified, everyone perceives the change in the same way, a relatively small group of easily identifiable people are affected, and the management of the change can be restricted to a small defined group. However, for soft changes it is difficult to define timescales, resource needs and objectives; people have different perceptions about the change and many may be affected and so control is distributed more widely. For hard changes and problems originate internally whilst soft changes it is externally.

Gleicher of Arthur D Little proposed the following formula

K x D x V > C
K = knowledge of what needs to be done
D = dissatisfaction with status quo
V = desirability of vision of the future
C = cost in both material and psychological

Safety cartoons

Found this site with good safety cartoons by Ted Goff. You need to pay to use them but it is quite inspirational just looking through the many examples

Lateral thinking examples

Final bits from Sloane's book. A few examples.

How to stop people chipping pieces off the Parthenon. Get chips of marble from the same quarry and distribute around the site each morning. People take them thinking they have got a piece of history.

Make the class look clever in front of the inspector. Tell kids to all put their hands up to answer questions. Put left hand up if they know the answer and right hand up if they do not.

How to become a millionaire by buying coconuts for $5 and selling for $3. Start as a billionaire and redistribute wealth in this way to the poor.

Why are items prices at £x 99p? Not to make price seem less. Required clerk to open till to get change so sale was recorded and clerk could not pocket the money.

You are driving in your 2 seater sports car. It isspouringg with rain. You see 3 people at a bus stop. An old friend. The man/woman of your dreams and an old lady whodesperatelyy needs to get to hospital. Which one do you pick up? Give keys to friend and get them to take old lady. Wait with you dream date.

You phone to get train time. You arrive half an hour early, why? On phone told train is 22:10 which you hear as 20 to 10 (i.e. 21:40).

Easy jet do not give free drinks. Make money and need one less toilet so can fit in more seats.

Great mistakes

More from Sloane's lateral thinking book (see previous postings). Examples that demonstrate Mark Twain's view that 'the greatest of all inventors is accident.'

A monk names Dom Perignon invented champagne when a bottle of wine accidentally had a second fermentation.

1839 Charles Goodyear discovered vulcanization when he accidentally dropped some India rubber mixed with sulphur on a hot stove.

3M invented a glue that was not very sticky, but used it to make Post-it notes.

Pfizer were testing a new drug to relieve high blood pressure. It failed, but men found it had an interesting side effect and the drug became Viagra.

In 1978 the Sony Corporation were trying to develop a small, portable tape recorder. They could make a small machine, but not one that would record. It was going to be written off. But the chairman (Mr Ibuka) realised that combined with light weight headphones they were also developing they could make a new product. People scoffed at the idea of a tape recorded that could not record and did not have a speaker, but we know it as the walkman.

1928 Alexander Fleming was working with infectious bacteria. One lab dish became contaminated with mould. Instead of throwing it away. Fleming examined further and discovered penicillin.

Bold statements

These are from Sloane's lateral thinking book (see previous posting)

Simon Newcomb (1835 - 1909) a leading US astronomer. He declared that flight by heavier-than-air objects was completely impossible. Even after the Wright brothers first flight he claimed that aeroplanes were impractical and worthless.

Dr Dionysius (1793 - 1859) professor of natural history and astronomy at London University. Warned that railway trains traveling at speed would asphyxiate their passengers through lack of air. Also, that steamships could not cross the Atlantic because the would need more coal than they could carry.

Ernst Werner von Siemens (1816 -1 1892) German engineer of the Siemens company. Declare that 'electric light will never take the place of gas.'

Charles Duell, commissioner of the US patents office said in 1899 that 'everything that can be invented has been invented.'

HM Warner of Warner brothers said in 1927 'who the hell wants to hear actors talk?'

Albert Einstein said in 1932 'there is not the slightest indication that nuclear energy will ever be obtainable.'

John Langdon Davies, fellow of the royal anthropological institute suggested in 1936 that 'by 1960 work will be limited to 3 hours a day.'

Ken Olson, CEO of DEC said in 1977 'there is no reason anyone would want a computer in their home.'

Gill Gates stated in 1981 '640k ought to be enough for anybody.'

Lateral thinking

I've been reading a book by Paul Sloane called "the leader's guide to lateral thinking skills." I don't think it is very good at covering lateral thinking. It quotes a lot of supposed examples which you can say may have been successful lateral thinking, but it misses the point that there are many more examples of where similar ideas have failed. Also, many of the examples are purely marketing. Suggesting lateral thinking is simply a way of selling people something they don't really need or packaging an old item so that people think it is something new. For example it quotes a "good example" as the people who worked out they could sell more tooth paste by making a larger hole in the tube and more shampoo by adding the word "repeat" to instructions.

However, there are some useful quotes and examples with a more general application. A few are below.
"Inaction s not an option." This is why there is the continual need to change.

Most companies focus their effort on efficiency and refining current processes. This is not enough. For example, refining the way to make LP's, 35mm film, gas lamps, horse drawn carts etc. does not reflect the fact that these items are largely obsolete.

Selling change to people requires managers to paint a good picture of where you will end up.

Change is uncomfortable. It means there will be winners and losers. Anyone involved risks failure.

You need to take calculated risks in change.

The concept of reversibility is a huge factor in the success of a business. Having a plan B is always a wise decision.

Studies have shown that people under pressure are less creative. Instead, people need realistic goals.

Need to remove the fear of the unknown and fear of failure.

Edward de Bono said "you cannot look in a new direction by looking harder in the same direction."

A ship is safe in harbour but that is not what ships are for

Being 85% ready and out there is better that being 99% ready and out there too late. Assess risks of imperfection before issue.

IT Projects

From Sunday Times 16 April 2006. Translate jargon from government

"We will seek to accelerate the pace of development as available resources permit" - It's going to take years and go way over budget

"The costs to date are for computer infrastructure and software. There will be other costs for implementation" - You don't get much for £6 billion. We're going to need a heap more money if this thing's ever going to fly.

"Our suppliers have been unable to maintain full availability without interruptionn during integration of multiple systems." - The software's useless and we haven't enough terminals

"Technical issues preclude reliable figures on compliance and throughputt." - This is monster is so out of controll we no longer have any idea what's going on.

Accidents in the home

Slightly bizarre claims in this page on the Saga website
http://www.saga.co.uk/health_news/article/79E1104A-504B-11D6-B896-00508BAEC55C.asp?bhcp=1

Claims that "according to the Royal Society for the Prevention of Accidents (RoSPA), most accidents in the home are caused by human error and are preventable." I had a quick look at the RoSPA site and couldn't find the reference. However, my view is that you can't say because an accident is caused by human error it is preventable. Especially as the Saga article goes on to say that "age plays a part in susceptibility to being hurt at home."

Anyway, some interesting data from the latest government figures (I presume this is from 2004 or 2005) include:

• 37,048 people had to go to hospital because of mishaps involving slippers in 1998.
• 1543 sustained injuries involving tissue paper,
• 371 had accidents putting on their underwear -
• 59 people got hurt in accidents involving Blu-tack!
• 4000 die annually in the home
• 70 die from accidents when doing DIY.

Lotus Notes

Interesting article in the current The Ergonomist (April 2006) number 430.
Talks about poor usability of Lotus Notes. Software tends to be bought because of its great power, but users use very little of this, and the bits they do use (email and diary) are the most difficult.
Article claims most of the problems would be relatively easy to fix, but usability never features highly on the lists of developers or procurement staff.

On the beach

A classic example of human factors. Took my two boys and two nephews to the beach the other day. The nephews were wearing wellington boots and my boys were wearing trainers. Of course it was one of the ones with boots on that got wet feet. The boots gave him a sense of security so he took more risks.

Drug trials

I see the conclusion now is that human was not involved in drug trials that put 6 people in hospital last month. It seems all protocol were followed and even in hindsight the reaction could not have been predicted.
This is another great example of how people understand risk. We all know there are risks in drug trials, which is why they are done in the first place. People don't seem to understand what that risk actually means. In particular, even we know there is a risk there is an expectation that no one will be harmed.
These articles give the latest update.
http://news.independent.co.uk/uk/health_medical/article356019.ece
http://news.independent.co.uk/uk/health_medical/article356019.ece

Ergonomics conference

It is the Ergonomics Society's annual conference this week. As a registered member of the society I supposed I should be there. But it is in Cambridge, which is difficult and expensive for me to get there, and I expect most delegates are more likely to be my competitors than potential clients.
There is a session devoted to the oil and chemical industry that I would have been particularly interested in. I must try and get a look at the papers being presented.
Next year's conference is in Nottingham. I'll try and make more of an effort to attend. I might even submit a paper.

Piper Alpha

I watched the BBC's Piper Alpha video at the weekend. Even though I have seen it several times before and studied the accident in some detail, it really highlighted what a tragedy the accident was.
I think a lot of people think that some people did some very bad things to cause the accident. In reality, the errors made were fairly minor. It is just that several happened together, and they combined with more fundamental weaknesses in the platform's design and company's management systems.
Especially relevant to some work I am doing at the moment is the importance of good incident response systems. Of all the systems and procedures we have, these ones have to work very well and they have to be practiced at length and often. How many companies can say that this is what they do?

Training by iPod

Found these two articles describing how a hospital is using iPods to give new staff induction training.
http://www.eveningtimes.co.uk/hi/news/5050526.html

http://www.cbronline.com/article_news.asp?guid=43FAF411-87A7-4528-BA2E-3DC06A277D19

I find the idea that an iPod is better for training than an interactive, one-to-one session is quite fascinating. People assume new technology will give benefits.

I wonder how they are going to demonstrate the "expected benefits to patients include improved safety and less exposure to clinical risk."

It is also a great example of where we measure achievement by saying people have received training, not whether they have learnt anything.

Silly signs

Found this Blog that shows silly signs. Good human factors stuff.
http://sillysigns.blogspot.com/

Mis-identification of chemicals

I picked up an interesting leaflet at the Hazards conference. It covers the problems of people using the wrong materials from drums and sacks. It points out that this can be because they labeled incorrectly, but usually because the person does not identify the correct drum or sack. There are many reasons for this, but poor labeling, easily confused materials names and badly organised storage are significant contributors.
The leaflet includes descriptions of 11 incidents and then goes on to discuss possible solutions. It should be really useful when dealing with situations where errors in selecting materials are possible providing a benchmark against which to judge the companies risk controls.

Conference - Hazards XIX

Attended the Hazards XIX conference in Manchester yesterday. This is always a good conference, organised by the Institution of Chemical Engineers, focused on safety in the process industry.
It is interesting that a few years ago human factors was one of the specialist topics in the parallel sessions but now it is an integral part of many of the main stream presentations.
I presented a paper regarding managing change. It might have been a bit ambitious, but I know some people appreciated it. I tried to make two points. First, most companies have systems to deal with hardware change, and virtually nothing for people and organisation changes. Second, most of the existing systems are purely change control rather than change management.