Los Almos study mistakes for prevention

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Mike Petrowski | Los Alamos National Laboratory

Los Alamos National Laboratory is taking proactive steps to prevent mistakes and improve human performance. Mike Petrowski, who works in performance assurance at Los Alamos, is at the forefront of this effort. According to a press release by Los Alamos National Laboratory, Petrowski explores the causes of significant mistakes and conducts training to increase awareness of the factors contributing to human error.

Petrowski's role spans across various laboratory groups, allowing him to have a comprehensive understanding of the factors that lead to errors. Los Alamos National Laboratory stated, "The field would become known as human performance improvement, which eventually became Mike’s professional purview."

One approach that has proven successful in preventing mistakes and decreasing injuries is the use of Learning Teams. These teams, endorsed by the Department of Energy in 2016, involve employees in assessing factors in minor incidents to mitigate the risk of more severe ones. This approach, along with ergonomic and process engineering improvements, has helped reduce injuries at one Lab facility from an annual rate of 10-12 to just three over a span of three years, according to the press release.

Petrowski emphasizes the importance of human performance improvement and its focus on people. He said, "How do we make people successful in what they’re doing? Because no one likes to make mistakes. No one likes consequences. We’d rather be successful at what we do. Human performance improvement tools take human fallibility into account to help us have successful outcomes."

Learning Teams, which are initiated by employees, play a crucial role in identifying opportunities for process improvement. The findings from these teams are then conveyed to management. This approach was adopted to overcome the hindrances faced during fact-finding missions following abnormal events. These missions aim to identify contributing deficiencies for future prevention, but were often hindered by unproductive intimidation factors, according to the press release.

In an industry where precision and safety are paramount, Petrowski recognizes the challenges in stopping and taking the time to ensure the best outcome. He said, "It’s hard for people to stop. We want to accomplish the outcome. So we try to overcome barriers to achieve, but that’s not always the best route. In our line of work, we don’t want to be guessing or trying. We want to be certain and know what to do."

Through the efforts of individuals like Mike Petrowski and the implementation of Learning Teams, Los Alamos National Laboratory is actively working towards preventing mistakes and improving human performance. By addressing the factors that contribute to errors and fostering a culture of continuous improvement, the laboratory aims to ensure successful outcomes and minimize the risk of more severe incidents.