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RM concept evolution 20190120
- 1. 201901 Concept Evolutionof Risk and Risk Management P:1/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ History and Concept Evolution of Risk Management Practical Perspective and Empirical Evidence in Manufacturing Sector (݀ᐊηπӼᆅᏢ/॥ ᓀ ᆅࡘ གྷ ў ) eshwayne@gmail.com Phone:0922516248
- 2. 201901 Concept Evolutionof Risk and Risk Management P:2/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Risk ? Definition (common sense) Ǹ Risk: Undesirable Result of Uncertainty Ǹ Result is the undesirable outcome or accident/injury. Ǹ Uncertainty is the unknown of odds or causal relationship as well as contributing factors to the outcome of the undesirable accident/injury. :KDW LV 5LVN Risk=Accident ॥ ᓀ =ཀ Ѧ (ཀ ϐ Ѧ ޑ ٣ ࡺ )
- 3. 201901 Concept Evolutionof Risk and Risk Management P:3/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Risk = The Act of GOD.. Risk: Undesirable Result of Uncertainty Ǹ Undesirable result/ outcome = accident, injury or loss. Ǹ Uncertainty is the unknown of odds or causal relationship as well as contributing factors to the undesirable outcome. :KDW LV 5LVN
- 4. 201901 Concept Evolutionof Risk and Risk Management P:4/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Risk = The Act of GOD.. Risk: Canȷt Be Avoided or Managed. Thus.. Risk Management : Beg (Bribe) the Mercy of Gods 5LVN 0 DQ DJ H P H Q W
- 5. 201901 Concept Evolutionof Risk and Risk Management P:5/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Risk = The Act of GOD.. Risk: Canȷt Be Avoided or Managed. Thus.. Risk Management : Snoop the Willing of God 5LVN 0 DQ DJ H P H Q W
- 6. 201901 Concept Evolutionof Risk and Risk Management P:6/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Empirical Evidence The Effect of Risk = The Act of GOD.. Risk Management : Beg (Bribe) the God മࣴ ܌ 1995ࣴ ز ൔ (IOSH84-S362ౢ ่ ᄬ ᡂ ϯ ჹ ך ୯ ᙍ ؠ ্ ቹ ៜ ϐ ࣴ ز ) ౼ ࡨ Չ ࣁჹ ܭ ᙍ ؠ ޑ ᜢ ߯ ό ᡉ ڙ ؠ ቷ ᕴ π բ ਔ ኧ ᆶ ౼ ࡨ Չ ࣁଯ ܭ ၗҁ ஏ ࡋ ե ܭ ҂ ڙ ؠ ቷ Ƕ( ी ᡉ ) Implication: Ǹό ࢂ ౼ ࡨ Չ ࣁ෧ Ͽ ᙍ ؠ /फ़ ե ॥ ᓀ ǸԶ ࢂ р ٣ ቚ у ౼ ࡨ Չ ࣁ... 50 R P P H Q WDU
- 7. 201901 Concept Evolutionof Risk and Risk Management P:7/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Risk = The Act of GOD.. Risk: Canȷt Be Avoided or Managed. Thus.. Risk Management: Mutual Aid 5LVN 0 DQ DJ H P H Q W
- 8. 201901 Concept Evolutionof Risk and Risk Management P:8/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Risk = The Act of GOD.. Risk: Canȷt Be Avoided or Managed. Thus.. Risk Management: Insurance, Diversify and Hedging 5LVN 0 DQ DJ H P H Q W
- 9. 201901 Concept Evolutionof Risk and Risk Management P:9/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Mind Your Own Business and Risk (Don’t Worry about God’s Decision ) ) U R P 50 WR 50
- 10. 201901 Concept Evolutionof Risk and Risk Management P:10/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Risk ? (common sense) Ǹ Risk = Accident ॥ ᓀ =ཀ Ѧ (ཀ ϐ Ѧ ޑ ٣ ࡺ ܈ ཞ Ѩ ) Ǹ Accident = an unfortunate incident that happens unexpectedly. Ǹ Accident = Unexpected, non-aware, unprepared (р Я ཀ ǵؒ Ԗ ჸ ᆶ ӳྗ ഢ) = What need to be expected, aware and prepared?What need to be expected, aware and prepared? :KDW LV 5LVN
- 11. 201901 Concept Evolutionof Risk and Risk Management P:11/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Risk = Accident Accident = Unexpected, non-aware, unprepared . Thus.. Risk Management : Underlying Wisdom of Survivor and Rule of Thumb Ǹ Accident Experiences Ǹ Customs and Taboos 5LVN 0 DQ DJ H P H Q W the New Guineans would not sleep under a dead tree. http://jareddiamond.org/Jared_Diamond/Welcome.html
- 12. 201901 Concept Evolutionof Risk and Risk Management P:12/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Risk = Accident Accident = Unexpected, non-aware, unprepared . Thus.. Risk Management : To Expect, Aware and Prepare Ǹ Potential and Possibility of Harm and Hazardous situation Ǹ Pay attention to harm situation and hazardous material or energy 5LVN 0 DQ DJ H P H Q W Accident = Hazard Hazard Definition (ISO-45001) Ǹ Hazard: sourcesource with a potential to cause injury and/or ill health SourceSource Ӓ্ྍٰޑǺӒᓀ ܄ ᐒ ఓ ഢ ǵϯ Ꮲ ࠔ ǵૈ ໆ ǵࡼ ኪ у ্ޣ ̯̯̯̯ +
- 13. 201901 Concept Evolutionof Risk and Risk Management P:13/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ ϯ Ꮲ ܄ Ǹ લ ਼ Ǹ ύ ࢥ Ǻ࡚ ࢥ ܄/ᄌ ࢥ ܄ Ǹ ڥ ֎ ֎ Ε / Ѓ १ Ε /Ҝ ጥ ௗ Ǹ ϯ Ꮲ ૈ ǺО ؠ ᛈ ࣆ ނ ܄ Ǹ Տ ૈ Ǻቜ ပ Ǹ ႝ ૈ Ǻག ႝ Ǹ ᐒ ఓ ǺϪ പ ֨ Ǹ ྕ ࡋ ૈ Ǻ؟ এ Ǹ Ꮣ ॣ ਁ Ǹ ෞ ᚆ /ߚ ෞ ᚆ ᒟ Γ Ӣ /Γ ᡏ π Ꮲ Ǹ ख़ ፄ ܄բ Ǹ Լ Ժ ମ ᓝ ለ ภ Ǹ բ բ ᆶ ᕉ ნ ܈ π ڀ ό ڐ ፓ ғ ނ ܄ Ǹ १ ނ ύ ࢥ Ǹ ࢉ ੰ Ј ܄ Ǹ ၸ മ/ၸ ॄ Ǹ ᙍ ៙ ঐ /ό ݤ ߟ ্ /ݔ ຎ 5LVN 0 DQ DJ H P H Q W Risk = Accident ЍЍЍЍ Hazard Accident = harm situation and hazardous material or energy . Thus.. Risk Management = Hazard Identification
- 14. 201901 Concept Evolutionof Risk and Risk Management P:14/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Risk = Accident = Hazard Risk Management = Hazard Identification Ε ߐ ભ ࣮ ډ ቹ (Ӓ ্ )൩ ໒ ᄳ Source: ጻሁቹׂ 5LVN 0 DQ DJ H P H Q W
- 15. 201901 Concept Evolutionof Risk and Risk Management P:15/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Risk = Accident =Hazard Risk Accident and Human Error can Be Avoided by Awareness! Thus.. Risk Management = Identify Hazards and Label them! 5LVN 0 DQ DJ H P H Q W
- 16. 201901 Concept Evolutionof Risk and Risk Management P:16/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Empirical Perspective The Effect of Hazard Communication is Unclear. Ǹ Hazards Communication and training is part of Injury and Illness Prevention Program. The solo effect of Hazards Communication program on injury incidence is not disclosed yet Ǹ The causal association from ȸHazard Label and Communication ȹvia ȸSafety Awareness and Behavior to ȸReduce Risk and Accident Incidenceȹ is not disclosed yet. 50 R P P H Q WDU
- 17. 201901 Concept Evolutionof Risk and Risk Management P:17/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Empirical Perspective The Effect of Hazards Communication is Unclear. Ǹ Safety knowledge Mediate the effect of Hazards Communication on Accident Prevention. Ǹ Lack off knowledge and awareness is always parts of accident. 50 R P P H Q WDU
- 18. 201901 Concept Evolutionof Risk and Risk Management P:18/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Academic Argument Situation Awareness is a Multi-dimensional Concept (Ѝ Black Box) . Ǹ Different situational understandings are incompatible, conflicts arise which in turn lead to safety-compromising incidents. Ǹ SA is heavily influenced by system design. Valid tools for assessing the affects of different design concepts on SA is needed in this area. Ǹ The relationship between distraction and SA is complex and being distracted does not simply lead to diminished SA. Ǹ In complex collaborative systems, more communications does not necessarily equate to better SA and tight coupling and sharing of information be not be appropriate. Ǹ There are ethical concerns associated with attributing ȶloss of SAȷ as a direct cause of accidents in safety critical systems. 50 R P P H Q WDU
- 19. 201901 Concept Evolutionof Risk and Risk Management P:19/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Empirical Evidence The Effect of Safety Training is Recognized. Ǹ It is general believed that training program is associated with the reduce of injury incidence. ȹ࣬ ߞ ȹ௲ ػ ૽ ግ ჹ ܭ Ⴃ ٛ ٣ ࡺ ᆶ ᙍ ؠ Ԗ ਏ Ǵՠ ࢂ ᛰ ਏε λ ᆶ ࢂ ց ᡉ Ӹ ӧ ݾ .. 50 R P P H Q WDU
- 20. 201901 Concept Evolutionof Risk and Risk Management P:20/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ5LVN 0 DQ DJ H P H Q W Source: OHSA USA https://www.osha.gov/harwoodgrants/ grantmaterials/fy2010/sh-21000-10 Right to KnowRisk = Accident =Hazard Risk and Human Error can Be Avoided by Awareness! Thus.. Regulation Risk Management = Hazards Communication, Notification and Training!
- 21. 201901 Concept Evolutionof Risk and Risk Management P:21/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ5LVN 0 DQ DJ H P H Q W Risk = Accident =Hazard Risk and Human Error can Be Avoided by Awareness! Thus.. Risk Management = Standards, Code of Conduct! e.g., Regulation, FM, Semi
- 22. 201901 Concept Evolutionof Risk and Risk Management P:22/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Inspiration of Taylar (Management Science) Heinrich (Accident Analysis) Analysis the task as a series of movement Review the happening of accident as a series of event (Domino Metaphor) ) U R P 50 WR 50 Frederick Winslow TaylorΔ1856-1915
- 23. 201901 Concept Evolutionof Risk and Risk Management P:23/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Hazard = Accident = Risk ? Ǹ Hazard: source with a potential to cause injury and/or ill health Ǹ Risk: effect of uncertainty (Definition of ISO-45001) Ǹ Effect is a deviation from the expected ȋ positive or negative. Ǹ Uncertainty is the state, even partial, of deficiency of information related to, understanding or knowledge of, an event, its consequence, or likelihood. Ǹ Risk is often expressed in terms of a combination of the consequences of an event and the associated likelihood of occurrence. :KDW LV 5LVN ЋЋЋЋ
- 24. 201901 Concept Evolutionof Risk and Risk Management P:24/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Hazard Ћ Accident Ћ Risk Ǹ Risk: effect of uncertainty Ǹ Effect is a deviation from the expected ȋ positive or negative. Ǹ Uncertainty is the state, even partial, of deficiency of information related to, understanding or knowledge of, an event, its consequence, or likelihood. Ǹ ӵՖϩӵՖϩӵՖϩӵՖϩӒ ্ Ꮴ ठ ॄ य़ ٣ ҹ (=٣ ࡺ )ޑȹ ნ ნ ნ ნ (changes in circumstances)ȹ Ǹ Risk or Safety depends on the context = Break down context and association Source: http://psas.scripts.mit.edu/home/get_pdf.php?name=1-1-Beginners-Tutorial-part1.pdf ॥ ᓀ Ǻ ा Ե ቾ ᆶ ࡘ ໆ ნ :KDW LV 5LVN
- 25. 201901 Concept Evolutionof Risk and Risk Management P:25/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Risk Ћ Hazard Ћ Accident Ǹ Chain/Series of Events or Behavior leads the victim to contact Hazard (Energy or Chemical ) • Hazard + Chain/Series of Events = Accident ೱ Ս ᒱ ৡ /ό Չ ࣁᏤ ठ ؠ ᜤ ว ғ :KDW LV 5LVN
- 26. 201901 Concept Evolutionof Risk and Risk Management P:26/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Risk = From Hazard via Series/Chain of events to Accident Ǹ ϩϩϩϩӒ ্ Ꮴ ठ ॄ य़ ٣ ҹ (=٣ ࡺ )ว ғ ၸ ำ ύ ޑ ೱ Ս ȹ٣ ҹ٣ ҹ٣ ҹ٣ ҹ ( series/chain of events)” Guidelines for Hazard Evaluation Procedures, 3rd Edition | AIChE Hazard (Source)= Event (behavior/Media) = Accident (Injury) :KDW LV 5LVN
- 27. 201901 Concept Evolutionof Risk and Risk Management P:27/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Risk = Series/Chain of events to Accident Risk and Accident can Be Avoided via.. Risk Management : Analysis and Stop the Series/Chain of Events = Take Actions and Add Defenses between Hazard and Loss/Victim ! 5LVN 0 DQ DJ H P H Q W ᛩᛩᛩᛩ! ቼቼቼቼ! ԳԳԳԳ! !!!! ٲٲٲٲ!!!! ᙠᙠᙠᙠ!!!!!!!! ڂڂڂڂ! ైైైై! ჾჾჾჾʳ ؈؈؈؈ʳൣൣൣൣʳʳʳʳ उउउउʳ ٲٲٲٲᙠᙠᙠᙠ! ࠃࠃࠃࠃ ਚਚਚਚʳ ᙑᙑᙑᙑ! ᎄᎄᎄᎄ!!!! 1920-30 national safety congresses (NSC)வ Չ ࣁӼ ӄ (behavioral aspects of safety.) ࠹ Ϟ В π Ӽ Γ Ը ዕ ૈ ၁ ޑ “3Eα ဦ ”Ǻ π ำ ׯ ๓ (Engineering, Ӓ ᓀ ޑ ᐒ ఓ ഢѸ ी ᆶ း Ӽ ӄ း )Ǵ ௲ ػ ૽ ግ (Education, ૽ ግ π Ӽ ӄ π բ ᆶ ᒥ Ӻ Ӛ Ӽ ӄ ำ ׇ ) ம ڋ ೕ ጄ (Enforcement, ࡹ ۬ ᅱ ࿎ ٣ ൂ Տ Ь ࢂ ց ග ٮ Ӽ ӄ ࡼ ᆶ ௲ ػ ૽ ግ ๏ π ) Ӛ բ Ӽ ӄ ೕ ጄ ᆶ ೕ ۓ ޑ ᇙ բ Ǵᔈ၀ޚTaylarࣽ Ꮲ ᆅ ޑ ᆒ ઓ -ܨ ှ ϩ ғ ౢ ࢬ ำ ύ ޑ Ӛ բ ᡯ Ǵ ϩ ё ૈ ޑ Ӓ ্ ᆶ ග р Ӽ ӄ ჹ
- 28. 201901 Concept Evolutionof Risk and Risk Management P:28/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Risk = Series/Chain of events to Accident Risk and Accident can Be Avoided via.. Risk Management : Ǹ Analysis and Break down the process or accident (Follow the example of Taylar) Ǹ Do something within the Series/Chain of Events! 5LVN 0 DQ DJ H P H Q W
- 29. 201901 Concept Evolutionof Risk and Risk Management P:29/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Risk = Series/Chain of events to Accident ໘ ભ - “࣮ р ( ፕ ᆶ ෳ )ȹё ૈ Ꮴ ठ ٣ ࡺ ޑ ნ ᆶ ወ ӧ લ ഐ 5LVN 0 DQ DJ H P H Q W
- 30. 201901 Concept Evolutionof Risk and Risk Management P:30/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Risk = Series/Chain of events to Accident Risk Management= Break down process+ Identify Hazard e.g., Job Safety/Hazard Analysis 5LVN 0 DQ DJ H P H Q W
- 31. 201901 Concept Evolutionof Risk and Risk Management P:31/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ5LVN 0 DQ DJ H P H Q W Risk = Series/Chain of events to Accident Risk Management= Break down process + Identify Hazard + Risk Matrix Ǹ Risk: effect of uncertainty (Definition of ISO-45001) Ǹ Risk is often expressed in terms of a combination of the consequences of an event and the associated likelihood of occurrence.
- 32. 201901 Concept Evolutionof Risk and Risk Management P:32/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ5LVN 0 DQ DJ H P H Q W Risk = Series/Chain of events to Accident Risk Management= Break down + Identify Hazard + Risk Matrix Ǹ e.g., ISO-45001
- 33. 201901 Concept Evolutionof Risk and Risk Management P:33/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ5LVN 0 DQ DJ H P H Q W Risk = Series/Chain of events to Accident Risk Management= Break down + Identify Hazard + Risk Matrix Ǹ e.g., HazOp Ӓ ্ Ϸ ё ᏹ բ ܄ϩ (1/3) ȉBy PID Ϫ ϩ ᗺ Ε ᇙ ำ ಒ (༾ ᢀ )
- 34. 201901 Concept Evolutionof Risk and Risk Management P:34/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ5LVN 0 DQ DJ H P H Q W Risk = Series/Chain of events to Accident Risk Management= Break down + Identify Hazard + Risk Matrix Ǹ e.g., HazOp Ӓ ্ Ϸ ё ᏹ բ ܄ϩ (2/3) ȉ ( ၸ Ꮴ Ї ୖ ኧ )ຑ ё ૈ Ѩ ნ
- 35. 201901 Concept Evolutionof Risk and Risk Management P:35/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ5LVN 0 DQ DJ H P H Q W Risk = Series/Chain of events to Accident Risk Management= Break down + Identify Hazard + Risk Matrix Ǹ e.g., HazOp Ӓ ্ Ϸ ё ᏹ բ ܄ϩ (2/3) ȉ ຑ ё ૈ ܄/ᝄ ख़ ࡋ (Ե ቾ ٛ ៈ )ᆶ ׯ ๓ ࡌ
- 36. 201901 Concept Evolutionof Risk and Risk Management P:36/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ5LVN 0 DQ DJ H P H Q W Risk = Series/Chain of events to Accident Risk Management= Break down + Identify Hazard + Quantify Risk Ǹ e.g., Dow Chemical FEI ഏ М ϯ Ꮲ О ؠ ᛈ ࣆ ࡰ ኧ • ࣮ϯᏢނОؠӒ্܄(MF) • ࣮ᇙ ำ చ ҹ (ᇙ ำ Ӓ্ว ғ ё ૈ ܄) • ࣮Ӓ্ࡕ ݀ ( ୍ ཞ Ѩ )
- 37. 201901 Concept Evolutionof Risk and Risk Management P:37/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Layers of Protection and Reliability Engineering(ᡣ ന ࡕ ᕴ Ѩ ᇤ फ़ ե ) 50 R P P H Q WDU Risk = Series/Chain of events to Accident Risk Management : Analysis and Stop the Series/Chain of Events = Take Actions and Add Defenses between Hazard and Loss/Victim !
- 38. 201901 Concept Evolutionof Risk and Risk Management P:38/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ ߥ ៈ ቫ ຫ ӭ ຫ ӳ ? Ե ໆ ᆶ ڗ ௭ 1. ଛ ޑ ೬ ฯ ᡏ (e.g, ሚ ᆶ ೱ ᙹ ᐒ ڋ ) 2.π ය ਔ ໔ ᆶ Ⴃ ᆉ Ҕ 3.ᇤ ൔᆶ ᇤ բ (ࠠ ࠠ Β ᒱ ᇤ ॥ ᓀ ) 4.ό ӕ ය /ό ӕ ቷ จ ഢǴس ޑ ӝ 5.В ࡕ ޑ ᆢ ៈ ԋ ҁ /ߡ ճ ܄ 6.س ޑ ё ࡋ /ᛙ ۓ ܄/࣬ ܄ Ӛ ᅿ Ꭹ ျ /ഢ ජ ᐒ ڋ ຫ ӭ Ǵё ࡋ ຫ ଯ Ǵ॥ ᓀ ຫ ե ǻ Ǹ Ꭹ ျ 0ഢජᐒ ڋ ຫ ӭ Ǵё ࡋ ᆶ س ፄ ᚇ ࡋ ຫ ଯ Ǵፄ ᚇ ࡋ ܢ ё ࡋ Ǹ Ꭹ ျ 0ഢජᐒ ڋ ຫ ӭ Ǵሡ ा ຫ ӭ ၗྍ ᆢ ៈ Ǵִ ๓ ܢ ᎍ Ԗ ਏ܄ Ǹ Ꭹ ျ 0ഢජᐒ ڋ ຫ ӭ Ǵᏹ բ Γ ຫ ܰ Ꮾ 0ᇤ ղ ܈ ሡ ा ׳ ӭ ਔ ໔ ૽ ግ Ǵ ܢ ᎍ Ԗ ਏ܄ᆶ ᔈᡂ ૈ ऐ Ƕ Risk = Series/Chain of events to Accident Risk Management : Analysis and Stop the Series/Chain of Events = Take Series of Protection and Defenses between Hazard and Loss/Victim 50 R P P H Q WDU
- 39. 201901 Concept Evolutionof Risk and Risk Management P:39/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Empirical Perspective ٛ ៈ ቫ ຫ ӭ ᆶ ೱ ᙹ ᐒ ڋ ຫ ፄ ᚇ ж ߄ ຫ Ӽ ӄ ǻ Hint: ଆࠃڜਚ/ு ሽ ࠃਚ Source: http://tx.technion.ac.il/~gordoncn/05072011/3.Nancy_presentation.ppt Safety Research 2011 Special Issue Complexity and Safety ග ᒬ ࣬ ᜢ வ Γ Ǵၢ ಥ π ำ ǵጕ ܄ᆶ ֽ ൂ ϡ ޑ ࡘ ᆢ ኳ Ԅ ٰ ࣮ ࡑ Ӽ ӄ ᆶ ٣ ࡺ Δ൧ ख़ س (ޑ ፄ ᚇ ϕ )ǴԶ ߚ ୴ చ Ў ೕ ۓ ک π ำ ഢ 50 R P P H Q WDU
- 40. 201901 Concept Evolutionof Risk and Risk Management P:40/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Empirical Perspective The Event-based thinking Go a Wrong way. )ـ ᐋ ό ـ ݅ 0ό ࣮ Γ Ӣ0ᒱ Ҭ ϕ բ Ҕ * Ћ 50 R P P H Q WDU
- 41. 201901 Concept Evolutionof Risk and Risk Management P:41/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ50 R P P H Q WDU Empirical Perspective The Event-based thinking Go a Wrong way. (٣ ෳ ё ૈ р ᒱ ᕉ ᆶ ٣ ࡺ ϩ ෳ চ Ӣࢂ ٿ ӣ ٣ )
- 42. 201901 Concept Evolutionof Risk and Risk Management P:42/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Empirical Perspective The Event-based thinking Go a Wrong way. (٣ ෳ ᆶ ٣ ࡺ ϩ ࢂ ٿ ӣ ٣ -Ӣ(ঁ ձ բ ࣁ)ɫ (༼ ޑ )݀ Composition Fallacy 50 R P P H Q WDU Source: Jens Rasmussen RISK MANAGEMENT IN A DYNAMIC SOCIETY: A MODELLING PROBLEM Safety Science Vol. 27, No. 2/3, pp. 183-213, 1997 Accident Ana1ysis: Combinatorial structure of possible accidents can easily be identified Operational decision making: Decision makers from separate departments in operational context very likely will not see the wood for the trees
- 43. 201901 Concept Evolutionof Risk and Risk Management P:43/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ ѝ ࣮ډ ว ғ ޑ ҽ Ǵ ࣮ό ډ ٗ ٤ ᔈ ၀ ว ғ ࠅ ؒ ว ғ ޑ ҽ р ٣ ό ڻ ܁ Ǵ܁ ޑ ࢂ ࡐ ӭ ࡐ ച ޑ Ӧ Б ࣁ ϙ ሶ ؒ р ٣ ǻ Empirical Perspective The Event-based thinking Go a Wrong way. (٣ ෳ ᆶ ٣ ࡺ ϩ ࢂ ٿ ӣ ٣ -Hindsight and Heuristic Bias(ࡕ ـ ϐ ܴ ᆶ ऀ ᢜ ߕ ) 50 R P P H Q WDU
- 44. 201901 Concept Evolutionof Risk and Risk Management P:44/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Risk Management = অ ҅ ᒱ ᇤ ܈फ़ ե ᡂ ౦ (Ѻ ံ ଝ =ᝄ Ӊ ݤ ᆅ ౦ த /ٛ ք ᓵ ᒱ ǵቚ ӭ ߥ ៈ ቫ ග ϲ ё ࡋ ) RM 2.0 Accident = Risk of Hazard + Omission (Out of Control) Accident = Problem of Reliability and Control RM 2.0 (Madness) : Obsessed in the game (blaming and fixing ) 50 R P P H Q WDU Risk = Series/Chain of events to Accident = Take Actions and Add Defenses between Hazard and Loss/Victim ! Empirical Perspective The Event-based thinking Go a Wrong way. Hindsight and Heuristic Bias
- 45. 201901 Concept Evolutionof Risk and Risk Management P:45/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ5LVN 0 DQ DJ H P H Q W Risk = Series/Chain of events to Accident Accident = Risk of Hazard + Omission (Out of Control) Risk Management= Identify Oversights and Omission (control management system factor) e.g., MORT Source: http://www.nri.eu.com/NRI1.pdf
- 46. 201901 Concept Evolutionof Risk and Risk Management P:46/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Inspiration of Deming (System Thinking) Reason (Accident Analysis) Risk is a Systematic and Organizational Problem Underlying Human Factor Organizational Context (Swiss Cheese Metaphor) ) U R P 50 WR 50
- 47. 201901 Concept Evolutionof Risk and Risk Management P:47/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Risk : Effect of Uncertainty Practical and Operational Meaning Ǹ Effect is a deviation from the expected ȋ positive or negative. Ǹ Uncertainty is the state, even partial, of deficiency of information related to, understanding or knowledge of, an event, its consequence, or likelihood. :KDW LV 5LVN Risk = f (changes in circumstances) = f (system, context) Risk Management = Manage the System RM 3.0 Accident = Technical+ Human + Organizational Factors (interaction)
- 48. 201901 Concept Evolutionof Risk and Risk Management P:48/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ What is System?What is System? ಔ ڀ Ԗ ࣬ ϕ ᜢ ೱ ܈܄ ࣬ ϕ բ Ҕ ޑ ಔ ᙃ (3.1)ޑ ा ન Ǵ೭ ٤ ा ન ߯ Ҕ ܭ ၲ ԋ Ҟ :KDW LV 5LVN Risk = f (changes in circumstances) = f (system, context) Accident is side effect of the operation (Safety and Risk is Incidental of the system ) Risk Management = Manage the System
- 49. 201901 Concept Evolutionof Risk and Risk Management P:49/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ What is System?What is System? -- Safety Culture (Psychological) Perspective Ǹሦ Ꮴ /ྎ ೯ ǵᕮ ਏԵ ਡ ǵӄ ୖ ᆶ .. :KDW LV 5LVN Risk = f (changes in circumstances) = f (system, context) Accident is side effect of the operation (Safety and Risk is Incidental of the system ) Risk Management = Manage the System
- 50. 201901 Concept Evolutionof Risk and Risk Management P:50/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Leadership and Management Imperfection, unprofessional, non-integrity :KDW LV 5LVN
- 51. 201901 Concept Evolutionof Risk and Risk Management P:51/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Leadership and Management Imperfection, unprofessional, non-integrity :KDW LV 5LVN
- 52. 201901 Concept Evolutionof Risk and Risk Management P:52/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ ჴ Ш ࣚ ᆶ ࣚ ၮ բ ޑЈ ඵ ኳ Ԅ Ǵӵ ӕ ᖻ ً ӵ Ֆ ӧ ό р ख़ ε ً ᅾ ޑ ග Π Ӄ ܢ ၲ ಖ ᗺ ཀ Ѧ ٣ ࡺ ѝ ࢂ ੌ р Н य़ ޑ ٣ ҹ (incidents) ٣ ࡺ ङ ࡕ চ Ӣ ࢂ ٣ Γ ޑ Չ ࣁ ኳ Ԅ (pattern) Ϧ љ ಔ ᙃ ่ ᄬ ǵ ೢ Ⴤ ϩ ቹ ៜ ک ༟ π ޑ Չ ࣁ ኳ Ԅ (model) ۭ ቫ ޑ root cause߾ ࢂ ଯ ቫ ܈ ঁ Ϧ љ ޑ ࡘ ᆢ ک ሽ ॶ ᢀ (value) Underlying Mental Models ፔ ၀ ϙ ሶ ǻ࡛ ሶ ǻ ள ӳ ό ӳ ǻࣁ ϙ ሶ ό ǻ :KDW LV 5LVN
- 53. 201901 Concept Evolutionof Risk and Risk Management P:53/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Incompatible(= Conflict) Goals Compromise integrity of all aspects :KDW LV 5LVN
- 54. 201901 Concept Evolutionof Risk and Risk Management P:54/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Γ ပ ჴ բ Ӽ ӄ ᆶ SOPǴ(ε ৎ Ҕ Ј /Ԗ Ј )൩ ё а Ⴃ ٛ ٣ ࡺ 5LVN 0 DQ DJ H P H Q W Risk = f (changes in circumstances) = f (system, context) Accident is side effect of the operation (Safety and Risk is Incidental of the system ) Risk Management = Manage the System (Safety Awareness)
- 55. 201901 Concept Evolutionof Risk and Risk Management P:55/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Ҕ Ј /Ҕ Κ פ р Ӛ Ⴃ ٛ ࡼ ޑ ወ ӧ લ ഐ ൩ ё а Ⴃ ٛ ٣ ࡺ 5LVN 0 DQ DJ H P H Q W Risk = f (changes in circumstances) = f (system, context) System/ Context= Technical Factor, Human Factor and Organizational Factor Risk Management = Manage Latent Failures in the System
- 56. 201901 Concept Evolutionof Risk and Risk Management P:56/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Risk Management = Golden Sample + Benchmark (а ന ٫ ं բ ࣁୖ Ե ୷ ྗ ) 5LVN 0 DQ DJ H P H Q W Risk = f (changes in circumstances) = f (system, context) System/ Context= Technical Factor, Human Factor and Organizational Factor Risk Management = Manage Latent Failures in the System
- 57. 201901 Concept Evolutionof Risk and Risk Management P:57/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Empirical Evidence ပ ჴ В த ᆅ /ᅰ ๓ ᅰ ऍ ൩ ૈ҉ ߥ Ӽ ந ǻ Source:http://opim.wharton.upenn.edu/risk/library/2007Elliott,PRK,etal_'EverydaySafety'.pdfჴ ࣴ ز ่ ݀ᡉ Ң Ǻ В த ᆅ ள ӳ(π ե /5Sӳ)ޑ Ϧ љ (࣬ ၨ ܭ π ଯ )Ǵ ځ ख़ ε ٣ ࡺ (О ؠ ᛈ ࣆ /ε ໆࢻ ᅅ )ޑ ܈ ฅ ؒ Ԗ ी ޑ ᡉ ৡ ౦ (܈ ጕ ܄ᜢ ߯ ) 50 R P P H Q WDU
- 58. 201901 Concept Evolutionof Risk and Risk Management P:58/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Natural selection and safety culture within a small/ medium sized enterprise (SME) AuthorǺBenjamin Brooks SourceǺJournal of Safety Research 39 (2008) 73ȉ85 ނᝡϺᆶύλҾޑӼӄЎϯނᝡϺᆶύλҾޑӼӄЎϯނᝡϺᆶύλҾޑӼӄЎϯނᝡϺᆶύλҾޑӼӄЎϯ(፦ ࣴ܄ ز ) ඔ ᛤ ύ λ Ҿ ޑ Ў ϯ ک Դ ᗥ ޑ Ј ඵ ኳ Ԅ )മၗᚈ Б Ј ᄊ ޑ ပ ৡ ᆶ ჹ ҥ * ӧ ύ λ Ҿ ऩ ा Չ ᆶ ပ ჴ Ӽ ӄ Ǵύ λ Ҿ ޑ ङ ඳ ે ๎ ܌ ༟ р ٰ ޑ ᢀ ۺ )ԋ ҁ Ե ໆǵૈ Ҕ 0ၸ ள ѐ ൩ ӳ*ᆶ Ӽ ӄ Ў ϯ ޑ ሽ ॶ Ǵٿ ޣ ໔ Ԗ ҁ ፦ ޑ ፂ ँ Ƕ Academic Argument Safety Culture is the result of Natural Section 50 R P P H Q WDU
- 59. 201901 Concept Evolutionof Risk and Risk Management P:59/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ The utility of a workplace injury instrument in prediction of workplace injury AuthorǺChristie Fullarton, Mark Stokes SourceǺAccident Analysis and Prevention 39 (2007) 28ȉ37 Ӽ ӄ Ў ϯ ࢂ ಔ ᙃ ᄽ ϯ ޑ ݀ǴႣ ෳ Κ (R^2: 23%)ό ӵ ಔ ᙃ ೕ ኳ (R^2: 46%) Academic Argument Number of employees Predict injury incidence Better than Safety Culture 50 R P P H Q WDU
- 60. 201901 Concept Evolutionof Risk and Risk Management P:60/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Deming’s Perspective on System System: composed of interrelated components • Quality (variation/ incident) is a systematic process. 5LVN 0 DQ DJ H P H Q W
- 61. 201901 Concept Evolutionof Risk and Risk Management P:61/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Deming’s Perspective on System 5LVN 0 DQ DJ H P H Q W
- 62. 201901 Concept Evolutionof Risk and Risk Management P:62/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Deming’s Perspective on System Theory of Profound Knowledge Appreciation of a system • A system is complex • Everyone must share the understanding and commitment to the aim • Leader understand the interconnectedness and interdependence • The people, free of fear and competition within the system can band together • Each component is obligated to contribute its best to the system as a whole. • Competitiveness within the system leads to loss for the system. • Each component works interdependently with the other components. 5LVN 0 DQ DJ H P H Q W
- 63. 201901 Concept Evolutionof Risk and Risk Management P:63/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Deming’s Perspective on System Theory of Profound Knowledge The psychology of change • Resistance to change- • Feel devalued and without ownership • Industrial style thinking has lead to management styles of command and control. • workplace and schools encourage individual completeness, authority, and one-right answer 5LVN 0 DQ DJ H P H Q W • People are born with intrinsic motivation, self- esteem, desire to learn, creativity and joy in accomplishment, and a need for freedom and belonging. • Leader must gain communicate a shared identity • leader serves the people with clear vision and guidance to empower them. • Training in creativity, communication and interpersonal skills may be necessary.
- 64. 201901 Concept Evolutionof Risk and Risk Management P:64/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ5LVN 0 DQ DJ H P H Q W Deming’s Perspective on System Theory of Profound Knowledge Theory of Knowledge • Learning process requires several steps (PDSA): 1) forming a theory, 2) making predictions based on past experiences, 3) testing the theory, 4) checking the results. • Knowledge is developed from the application of theory. • Theory provides a window from which to view the situation and gives meaning to experience. • Prediction based in theory provides a foundation for planning a course of action.
- 65. 201901 Concept Evolutionof Risk and Risk Management P:65/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ5LVN 0 DQ DJ H P H Q W Deming’s Perspective on System Theory of Profound Knowledge Understanding Variation • Variation is a natural, inevitable part of life. • The goal of continuous improvement is to reduce the range of variation over time, and adjusting the level to the desired level. • Almost all variation within a process is due to chance causes, inherent in the design of the process. • Management controls the design of the process. • People within the system are limited by that design.of action. Shewhart Cycle
- 66. 201901 Concept Evolutionof Risk and Risk Management P:66/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Understanding Variation Common cause or Specific cause 5LVN 0 DQ DJ H P H Q W
- 67. 201901 Concept Evolutionof Risk and Risk Management P:67/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ ٣ ࡺ ޑว ғ (=ୢ ᚒ )ࠠޑ ᄊ ࢂ ǻ • ྕ Н ฆ ߙ ຂ ǻ=Ӈ এ Ο Ё ߚ В ϐ ൣ • ཀ Ѧ (ᚆ ဂ ᗺ )ǻ=ࢌ Γ ό λ Ј ҍ ᒱ /Ѩ த 5LVN 0 DQ DJ H P H Q W Understanding Variation Common cause or Specific cause ό ӕ ٣ ࡺ ᜪ ࠠ ޑӢ ᔈ Б Ԅ ࢂό ӕ ٣ ࡺ ᜪ ࠠ ޑӢ ᔈ Б Ԅ ࢂό ӕ ٣ ࡺ ᜪ ࠠ ޑӢ ᔈ Б Ԅ ࢂό ӕ ٣ ࡺ ᜪ ࠠ ޑӢ ᔈ Б Ԅ ࢂ …?
- 68. 201901 Concept Evolutionof Risk and Risk Management P:68/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ 14.50 15.00 15.50 16.00 16.50 17.00 0 5 10 15 ᛀီणႨቹ ၲࡨ FMEA ം ᠲ ᒔ ᎁ ࢨ ᠲ ᙇ ࡳ ฆ ։ ࣫ / ؾ ᑑ ࡳ ᇞ ެ ࢨ ໌ ທ ¢¡¤£ ¥¢¦¤£ §¡¤£ ¨¢©¤ ! # $% '( )0 1 23 45 6# 7 3 89 @ AB M/D6Spacer CD IQA EF GH I PQ R S T / UV WX I §Q Y` ab cd e¤f g¤¦ h ! ip qr s3 £ Y` tu v wyx€ƒ‚„y… † f ޏ ኙ ऱ ױ ۩ ࢤ ေ ۷ ‡ˆ‰ ‘ ’“ SEP QCT NOV DEC W49 W50 W51 ”• –˜—™– ”• –˜—™– ”• –˜—™– ”• –˜—™– ”• –˜—™– ”• –˜—™– dfe˜gihj˜k lm no lm no lm no lm no Memo 5600-1023 V pqr P-FEED s / tuv dewx y z V wx y 1,4,6 Spec 64-02-225-001 {|}~ wx y 1,2,3,4,6 wx y jk€ 1,2,3,4,6 ‚ƒ d„ P-FEED … / †de 2,3,4,6 V P-FEED 1 de wx y WHO wx y 3,4,6ROBOT PICK-UP de SCHEDULE (monthlyweely) ~ ‡ˆ‰ (evidence) pqŠpq‹ Œ (V) V ޏ ኙ ऱ ኔ ਜ ૠ ቤ SPC ᧭ ဳ /อ ૠ ֫ ऄ ڶய ࢤ उ ։ ࣫ Goal ppm Actual Hold ᑉ ழ ጥ ࠫ Chronic Excursion ം ᠲ ᇞ ެ ী ᓰᠲሒګী Excursion Chronic ޏ۩೯ਢܡڶய టڂਢܡإᒔ Doc ߓอᑑᄷ֏ Excursion Excursion Chronic ڶ ྤ C P A D S Theory of Knowledge PDSA 5LVN 0 DQ DJ H P H Q W
- 69. 201901 Concept Evolutionof Risk and Risk Management P:69/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ PDSA Organization Viewpoint- ISO-45001 5LVN 0 DQ DJ H P H Q W
- 70. 201901 Concept Evolutionof Risk and Risk Management P:70/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Empirical Evidence Association Between OSHMS and Accident IncidenceӢ ݀ ᜢ ߯ ࢂ ǻ ပ ჴ В த ᆅ =෧ Ͽ ٣ ࡺ ǻ ҭ ܈ ٣ ࡺ ଯ ω ख़ ຎ ᆶ ပ ჴ ᆅ ǻ ჴ ࣴ ز ่ ݀ᡉ Ң Ǻ Ꮴ Ε ᙍ Ӽ ፁ ᆅ س ޑ ؒ Ԗ К ၨ ե ٣ ࡺ rate of accidents at work ว ғ ၨ ӭ ٣ ࡺ (٣ ࡺ ଯ )ޑ ω གྷ ा Ꮴ Ε ᆶ ڗ ள ᆅ س ᇡ 50 R P P H Q WDU
- 71. 201901 Concept Evolutionof Risk and Risk Management P:71/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Empirical Evidence Association Between OSHMS and Accident IncidenceӢ ݀ ᜢ ߯ ࢂ ǻ ပ ჴ В த ᆅ =෧ Ͽ ٣ ࡺ ǻ ҭ ܈ ٣ ࡺ ଯ ω ख़ ຎ ᆶ ပ ჴ ᆅ ǻ ჴ ࣴ ز ่ ݀ᡉ Ң Ǻ Ꮴ Ε ᙍ Ӽ ፁ ᆅ س ࡕ ޑ π ؒ Ԗ ᡉ ৡ ౦ к ځ ໆԖ К ၨ ӭ ޑ Ӽ ፁ ࢲ 50 R P P H Q WDU
- 72. 201901 Concept Evolutionof Risk and Risk Management P:72/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Practical Perspective Why OSHMS is Not working (to reduce Injury or accident incidence) ? ǸThe System is viewed as fragmental component and process, and process is viewed as procedure (paper work) Ў ҹ ɫ Profound Knowledge of the system/ organization ǸLack of knowledge (variation, and mitigation of accident and risk)લ Ю ࣬ ᜢ ޕ ᆶ ፕ ǸLack of Appreciation (the SYSTEM, and mental psychology )ጁ ள ѝ ഭ ౢ ૈ ճ Ҕ ᆶ KPI 50 R P P H Q WDU Ћ
- 73. 201901 Concept Evolutionof Risk and Risk Management P:73/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ ɠɠɠɠ ɨɨɨɨ (Cross-Sectional) Organizational Context ᐉ ᘐ य़ )ϩ π ό ӝ բ *! ಔ ᙃ ϣ ޑ ݾ ღ ճ ǵᔅ ࢴ Ў ϯ ǵၗૻ/ ೢ ࣚ य़ ܈ Ь ٣ ޣ ޑ Ї Ꮴ ɨɨɨɨ 50 R P P H Q WDU Practical Perspective
- 74. 201901 Concept Evolutionof Risk and Risk Management P:74/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ (Longitudinal) Drift to Failure ᕵ ᘐ य़ )Ӽ ӄ ᒿ ਔ ໔ ૰ ଏ * Safety Margin Shrink over time= • Variance Expand over time • Behavior migrate toward boundary of acceptable performance. • System Envelop Shrink over time (second law of thermodynamics) Systems and organizations migrate toward accidents (states of high risk) under cost and productivity pressures in an aggressive, competitive environment 50 R P P H Q WDU Practical Perspective Source: Jens Rasmussen RISK MANAGEMENT IN A DYNAMIC SOCIETY: A MODELLING PROBLEM Safety Science Vol. 27, No. 2/3, pp. 183-213, 1997
- 75. 201901 Concept Evolutionof Risk and Risk Management P:75/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Deming is some kind of Guru (in some degree)… 50 R P P H Q WDU Bigger Question: “How a good person fix the bad system? “ There is no easy way, simple answer nor empirical knowledge.. Big Question: “Human behavior is not simple statistic or linear equation” The probability of human error is NOT Normal Distribution nor Reasonable Practical Perspective
- 76. 201901 Concept Evolutionof Risk and Risk Management P:76/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Ꮲ ೌ ࣚ ݾޑ ៏ ᆶ ε ࠌ ୢ Ǻ٣ࡺᆶཀѦૈۭډόૈႣٛ٣ࡺᆶཀѦૈۭډόૈႣٛ٣ࡺᆶཀѦૈۭډόૈႣٛ٣ࡺᆶཀѦૈۭډόૈႣٛǻǻǻǻ ό ૈ Normal Accident Theory Sociologist Charles Perrow,(1984) identifies three conditions that make a system likely to be susceptible to Normal Accidents: 1.The system is complex 2.The system is tightly coupled 3.The system has catastrophic potential Redundancy ᆶ ё ࡋ : 1. ᡣ س ׳ ፄ ᚇ ǵ׳ ό ё 2.ᡣ ᏹ բ ޑ Γ ե ૈ ( ߞ س ฯ ᡏ /Ѩ ѐ ղ ᘐ Κ ) 3. ᡣ Γ ۹ ຎ Ӽ ӄ ଓ ғ ౢ ਏ ǵೲ ࡋ ǵന ε ϯ 4.ಔ ᙃ Ѧ ᕉ ნ ޑ ᡂ ᎂ ᆶ ᕮ ਏᓸ Κ ૈ High Reliability Organization Five characteristics of High Reliability Organizations that have been identified ȐWeick, K. E.; Kathleen M. Sutcliffe, 2001.ȑ that keeps them working well when facing unexpected situations. 1.Preoccupation with failure(٣ Ⴃ གྷ ё ૈ Ѩ ਏѨ ޑ ნ ) 2.Reluctance to simplify interpretations (ל ܔ ᙁ ൂ ޑ ှ ញ Ǵӭ ు Ε ଓ ୢ ൳ ঁ why) 3.Sensitivity to operationsȐჹ ܭ ၮ բ ௵ ག ȑ 4.Commitment to resilience(܍ ᒍ Ε ၗྍ ) 5.Deference to expertiseȐ൧ ख़ ȑ Academic Perspective 50 R P P H Q WDU
- 77. 201901 Concept Evolutionof Risk and Risk Management P:77/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Academic Perspective 50 R P P H Q WDU Source: Scott D. Sagan, The Limits of Safety, 1993, p. 25.
- 78. 201901 Concept Evolutionof Risk and Risk Management P:78/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ50 R P P H Q WDU Practical Perspective
- 79. 201901 Concept Evolutionof Risk and Risk Management P:79/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ50 R P P H Q WDU Practical Perspective NASA Way Close-Call Initiative • committed to non-retribution incident reporting. • Analysis of close-calls, incidents, and mishaps can be effective in identifying unforeseen complex interactions if the proper attention is applied. • Develop corrective actions against the identified root causes by applying human factors engineering.
- 80. 201901 Concept Evolutionof Risk and Risk Management P:80/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ50 R P P H Q WDU Practical Perspective Human Factor Engineering • Easier to do right and harder to do wrong.
- 81. 201901 Concept Evolutionof Risk and Risk Management P:81/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ50 R P P H Q WDU Practical Perspective Close-Call (Near Miss) Initiative - Entangled Curse from Heinrich • The burden of investigation is expanded exponentially
- 82. 201901 Concept Evolutionof Risk and Risk Management P:82/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ50 R P P H Q WDU Practical Perspective Human Factor Engineering – Ownership of Accountability?! • Moral risk and unexpected physiological side effect…
- 83. 201901 Concept Evolutionof Risk and Risk Management P:83/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ50 R P P H Q WDU Practical Perspective Tailor-made and Context fitting • Don’t pursue perfect or risk-free. • Limitations are inevitable. • Less is More. • Few is Good. RCA: Root Cause Analysis; JSA: Job Safety Analysis; FMEA: Failure Model Effect Analysis; HazOp: Hazard and Operability Study; FTA: Fault Tree Analysis; ETA: Event Tree Analysis; LOPA: Layer of Protection Analysis
- 84. 201901 Concept Evolutionof Risk and Risk Management P:84/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Inspiration of Leveson (STAMP) Hollnagel (FRAM) RM 3.0 : Risk is a Systematic Issue and Accident is Probability RM 4.0 Redesign the System and Reform Metal ModelRedesign the System and Reform Metal Model ) U R P 50 WR 50 Leveson (Macro viewpoint) : • Control the interaction and interface among components • Redesign the Controlling system (put safety requirement and constraints in design phase) Hollnagal (Micro viewpoint) : • Accident is emerged from the functional resonance (interaction among components) • Build Model and Simulate the Resonance (tail event)
- 85. 201901 Concept Evolutionof Risk and Risk Management P:85/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Risk : Effect of Uncertainty Practical and Operational Meaning Ǹ Effect is a deviation from the expected ȋ positive or negative. Ǹ Uncertainty is the state, even partial, of deficiency of information related to, understanding or knowledge of, an event, its consequence, or likelihood. :KDW LV 5LVN Risk = f (changes in circumstances) Risk Management = Rate/Odds of Improvement Rate/Odds of Deterioration Periodic Maintenance, Program or Task Force for anti-deterioration RM 4.0 Accident and Risk are Systematic Problem (Boiling Frog/ Time Bomb)
- 86. 201901 Concept Evolutionof Risk and Risk Management P:86/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Risk : Effect of Uncertainty :KDW LV 5LVN Risk = f (changes in circumstances) : Dynamic Equilibrium and Cyclic Fluctuation Systematic view of Change- Loop and Feedback Structure Source: https://thesystemsthinker.com/reinforcing-and-balancing-loops-building-blocks-of-dynamic-systems/
- 87. 201901 Concept Evolutionof Risk and Risk Management P:87/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ:KDW LV 5LVN Risk = f (changes in circumstances) : Dynamic Equilibrium and Cyclic Fluctuation Systematic view of Change- Loop and Feedback Structure 1+1Ћ2 : the interaction is non-linear! Real World Situation and Manager Faced Every Day… Source: https://thesystemsthinker.com/reinforcing-and-balancing-loops-building-blocks-of-dynamic-systems/
- 88. 201901 Concept Evolutionof Risk and Risk Management P:88/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ:KDW LV 5LVN Risk = f (changes in circumstances) : Dynamic Equilibrium and Cyclic Fluctuation Basic Operation or Production SystemBasic Operation or Production System • Work pace/ pressure Is Balanced with External Demand • Work pace/ pressure Reinforce (possibility of ) Burnout Source: Nicolas Dulac “A Framework for Dynamic Safety and Risk Management Modeling in Complex Engineering Systems” MIT Ph D Dissertation
- 89. 201901 Concept Evolutionof Risk and Risk Management P:89/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ:KDW LV 5LVN Risk = f (changes in circumstances) : Dynamic Equilibrium and Cyclic Fluctuation Operation or Production SystemOperation or Production System ++ Rework Mistake • Work pace/ pressure Is Balanced with External Demand • Work pace/ pressure Reinforce (possibility of ) Burnout • Burnout Reinforce (possibility of ) Rework, Rework Reduce System Rate and Output Source: Nicolas Dulac “A Framework for Dynamic Safety and Risk Management Modeling in Complex Engineering Systems” MIT Ph D Dissertation
- 90. 201901 Concept Evolutionof Risk and Risk Management P:90/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ:KDW LV 5LVN Risk = f (changes in circumstances) : Dynamic Equilibrium and Cyclic Fluctuation Operation or Production SystemOperation or Production System ++ Rework Mistake + Safety/Quality Mechanism • Work pace Is Balanced with Demand • Work pace Reinforce Burnout • Burnout Reinforce Rework, • Rework Reduce Rate and Output • Safety/Quality Reduce Rework/Mistake • Resource/Pressure Bind Safety/Quality Source: Nicolas Dulac “A Framework for Dynamic Safety and Risk Management Modeling in Complex Engineering Systems” MIT Ph D Dissertation
- 91. 201901 Concept Evolutionof Risk and Risk Management P:91/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ:KDW LV 5LVN Risk = f (changes in circumstances) : Dynamic Equilibrium and Cyclic Fluctuation Safety Dynamic During OperationSafety Dynamic During Operation Source: Nicolas Dulac “A Framework for Dynamic Safety and Risk Management Modeling in Complex Engineering Systems” MIT Ph D Dissertation Why Organization Drift to Risky Status?Why Organization Drift to Risky Status? • Internal Resource Constraint • External Pressure Driving • Problem Solving Orientation. (short tern) • Pressure/Risk Accumulation. (long term)
- 92. 201901 Concept Evolutionof Risk and Risk Management P:92/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ System Completion Rate Schedule Delays Work Rate - + + Pressure to Deliver + Safety and Integration Priority - Resource Pressure Safety and Integration Resources - + + R1 Burnout Cycle B1 Burnout Rework Cycle R4 Accumulating Waivers R2 Delays cause Pressure Satisfaction of Funding Organization Burnout + - Quality and Timeliness of Safety and Integration Analyses - Design Tasks to be Reworked Unsatisfied Safety Requirements - Subtle Mistakes - System Lifecycle Cost - + + Operational Workarounds + Safety Rework Cycle R3 B/R 1 Resource Allocation B/R 2 Cost Overruns Source: Nancy G. Leveson A Systems Approach to Safety Engineering Systematic Equilibrium and Resource Constraints ಔᙃԖӵОጂǴό ё ૈ ុ у ೲ ೲ ࡋ ຫ ז ǵߔ Κ ຫ ε /ा ຫ ε ૈ ໆ ೲ ࡋ ຫ ז ǵ፦ ໆ ᡂ ε (࣬ ჹ ፕ ) ፦ ໆ ຫ ε Ǵу ೲ ܌ ሡ ૈ ໆ ຫ ε :KDW LV 5LVN Risk = f (changes in circumstances) : Dynamic Equilibrium and Cyclic Fluctuation Safety Dynamic During OperationSafety Dynamic During Operation Continuous Improvement is a Dream
- 93. 201901 Concept Evolutionof Risk and Risk Management P:93/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Source: Nancy G. Leveson A Systems Approach to Safety Engineering Risk = f (changes in circumstances) : Dynamic Equilibrium and Cyclic Fluctuation Safety Status Cyclical FluctuationSafety Status Cyclical Fluctuation :KDW LV 5LVN
- 94. 201901 Concept Evolutionof Risk and Risk Management P:94/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Source: Nancy G. Leveson STPA handbook 5LVN 0 DQ DJ H P H Q W Risk = f (changes in circumstances) : Dynamic Equilibrium and Cyclic Fluctuation Risk Management= Modeling+ Stimulation and Sensitivity Analysis •safety must be designed and built into aircraft just as are performance, stability, and structural integrity - Manage the management (of hazard and risk) •takes a larger view of hazards than just failures •emphasizes analysis rather than past experience and standards •Recognition of tradeoffs and conflicts:
- 95. 201901 Concept Evolutionof Risk and Risk Management P:95/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Source: Nancy G. Leveson STPA handbook 5LVN 0 DQ DJ H P H Q W Risk = f (changes in circumstances) : Dynamic Equilibrium and Cyclic Fluctuation Risk Management= Design+ Testing+ Fielding
- 96. 201901 Concept Evolutionof Risk and Risk Management P:96/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Source: Nancy G. Leveson STPA handbook 5LVN 0 DQ DJ H P H Q W Risk = f (changes in circumstances) : Dynamic Equilibrium and Cyclic Fluctuation Risk Management= Organizational Analysis
- 97. 201901 Concept Evolutionof Risk and Risk Management P:97/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Source: Nancy G. Leveson STPA handbook 5LVN 0 DQ DJ H P H Q W Risk = f (changes in circumstances) : Dynamic Equilibrium and Cyclic Fluctuation Risk Management= Organizational Analysis • Ownership/ Authority • Responsibility/ Accountability
- 98. 201901 Concept Evolutionof Risk and Risk Management P:98/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Activities Analysis • the primary activity of the organization, 1~2 functional areas of business dominate. • identify/ classify activities into functional areas, and list them in the order of importance. • divide and sub-divide the whole work into smaller homogeneous units so that the same may be assigned to different individuals. • it is important to divide the entire work into manageable units. • the job constitutes the basic building block in building up an organizational structure. Risk = f (changes in circumstances) Risk Management= Organizational Analysis Peter F. Drucker: (1909-2005) Organization Analysis: • Activities • Decisions • Relations 5LVN 0 DQ DJ H P H Q W Decision Analysis • the degree of futurity in the decision; • the impact that decision has on other functions • the character of he decision determined by a number of qualitative factors, such as, 'basic principles of conduct, ethical values, social and political beliefs etc., and
- 99. 201901 Concept Evolutionof Risk and Risk Management P:99/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ5LVN 0 DQ DJ H P H Q W Decision Analysis (conti.) • whether the decisions are periodically recurrent or rates as recurrent decisions may require a general rule whereas a rate decision is to be treated as a distinctive event. • A decision should always be made at the lowest possible level and so close to the scene of action as possible. Relations Analysis • downward, upward and lateral (side-ways) relations must be analysed to determine the organization structure. These relationships are vertical, lateral and diagonal. • Vertical relationship: a superior-subordinate relationship • Lateral relationship: an expert or specialist advising a manager at the same level, • Diagonal relationship: a specialist exercises authority over a person in subordinate position in another department. Risk = f (changes in circumstances) Risk Management= Organizational Analysis
- 100. 201901 Concept Evolutionof Risk and Risk Management P:100/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Source: Nancy G. Leveson STPA handbook 5LVN 0 DQ DJ H P H Q W Risk = f (changes in circumstances) : Dynamic Equilibrium and Cyclic Fluctuation Risk Management= Reshape Metal Model and Organizational Culture • Ownership/ Authority • Responsibility/ Accountability Economics of Violating
- 101. 201901 Concept Evolutionof Risk and Risk Management P:101/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ50 R P P H Q WDU Practical Perspective Internal Resource/ External Pressure Dominated System Result of System • The Richer, The Safer • External Audit Works • Accident Shapes Priority • Perceived Changes Priority • Delay exits among cycles • Resulted in unexpected Variance • Reminder: Deming
- 102. 201901 Concept Evolutionof Risk and Risk Management P:102/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Boiling Frog-Organizational Drift to failure is like a frog being slowly boiled alive. • How you identify the signal from noise ? Source: Erik Hollnagel Understanding How Something Happens – When It Works And When It Fails Hint: Γ ޑ ᄊ ࡋ ᜤ а ޔ ௗ ෳ ໆ(᠋ ځ ق ό ӵ ᢀ ځ Չ ) ౦ த ٣ ࡺ ҹ ኧ ပ ࡕ ࡰ Ӛ ᅿዽ ਡ /ْ ᔠ ว લ Ѩ ኧ ӭ ჲ ё ᒏ ࢂ ᒿ ᐒ ᡂ ౦ (noise) ໆϯ ࡰ ޑ ᡂ ϯ Ԗ ࿗ (Fractal)ޑ ࠠ -ᜤ а ղ ᘐ signal or noise 50 R P P H Q WDU Practical Perspective
- 103. 201901 Concept Evolutionof Risk and Risk Management P:103/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Boiling Frog-Organizational Drift to failure is like a frog being slowly boiled alive. • How the drifting (to the states of high risk) be sensed ? • Type One and Type Two error ? (λ ᚒ ε /ਫ਼ ٰ Α ) Source: Erik Hollnagel Understanding How Something Happens – When It Works And When It Fails 50 R P P H Q WDU Practical Perspective
- 104. 201901 Concept Evolutionof Risk and Risk Management P:104/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ50 R P P H Q WDU Practical Perspective Find Tail Event by Simulation Ǹ Resource ConstraintsǺ Ε ӭ Ͽ ၗྍ ($, Γ Κ /ਔ ໔ /ݙ ཀ Κ )ࣁᐒ ե ؠ ᜤ բ ྗ ഢǻ Modeling and Simulation Require Demanding Resource Ǹ Mindful Choice and Decision(ᜫ ። ܺ ᒡ ), No free lunch. (Opportunity Cost and ࠠ /ࠠ Β ᒱ ᇤ ॥ ᓀ ό ࣁ႟ ) The trade-off between Overkill or Under Preparation.
- 105. 201901 Concept Evolutionof Risk and Risk Management P:105/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ50 R P P H Q WDU Practical Perspective Organizational Analysis Ǹ No Perfect Organization Source: Scott D. Sagan, The Limits of Safety, 1993, p. 25.
- 106. 201901 Concept Evolutionof Risk and Risk Management P:106/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ50 R P P H Q WDU Practical Perspective Reshape Metal Model and Organizational Culture Ǹ Ј ၉ ε ߵ ᓀ Ǹ ҥ ᆶ ᢀ ᗺ ό ӕ =॥ ᓀ ᆶ ճ ό ჹ ᆀ =ፂ ँ ჹ ҥ ᆶ લ Ю ߞ Һ (e.g., മvsၗ) Ǹ а ي բ ߾ Ǻࡰ Ꮴ ा ձ Γ ܰ ǵԾ ך ा ന ᜤ Source: https://negotowin.blogspot.com/Source The Five Dysfunctions of a Team
- 107. 201901 Concept Evolutionof Risk and Risk Management P:107/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Activities Analysis • job constitutes building block in building up an organizational structure. 50 R P P H Q WDU Practical Perspective Risk Management= Organizational Analysis Ǹ Art of Politic (Not Science! ) Ǹ the process of making decisions that apply to members of a group Politics is much more difficult than physicsPolitics is much more difficult than physics.. Einstein Decision Analysis (conti.) • Decision made at the lowest possible level and close to the scene Relations Analysis • These relationships are vertical, lateral and diagonal.
- 108. 201901 Concept Evolutionof Risk and Risk Management P:108/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Practical Perspective Organizational Structure (infrastructure) is some source of Risk • By function/ Product / Geographical • Matrix 50 R P P H Q WDU
- 109. 201901 Concept Evolutionof Risk and Risk Management P:109/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰConclusion and Discussion Risk0.0 = f (Changes in Circumstances) :
- 110. 201901 Concept Evolutionof Risk and Risk Management P:110/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰConclusion and Discussion Risk Management0.0 (Manage Bad Luck) Beg (Luck) , Gamble, Mutual Aid and Insure (Financial Tool)
- 111. 201901 Concept Evolutionof Risk and Risk Management P:111/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰConclusion and Discussion Risk1.0 = f (Changes in Circumstances) :
- 112. 201901 Concept Evolutionof Risk and Risk Management P:112/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰConclusion and Discussion Risk Management1.0 (Manage Potential Hazard and Danger) Aware, Communicate, Educate, Legislate
- 113. 201901 Concept Evolutionof Risk and Risk Management P:113/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰConclusion and Discussion Risk2.0 = f (Changes in Circumstances) :
- 114. 201901 Concept Evolutionof Risk and Risk Management P:114/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰConclusion and Discussion Risk Manageme2.0 (Manage Event and Behavior that leads to accident) Analysis, Prioritize, Control and Restrain (Add hardware detection, protection and interlock, build up SOP, golden sample benchmark or auditing) Divide and ConquerDivide and Conquer
- 115. 201901 Concept Evolutionof Risk and Risk Management P:115/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰConclusion and Discussion Risk3.0 = f (Changes in Circumstances) :
- 116. 201901 Concept Evolutionof Risk and Risk Management P:116/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰConclusion and Discussion Risk Manageme3.0 (Manage the Organization and System) PDSA, Accumulate and unveil underlying knowledge and metal mindset Trial ErrorTrial Error in managing people, system and organization (survivor bias) However, Organizational Culture and System Dynamic are the Result of Natural Selection and Evolution….difficult to change..
- 117. 201901 Concept Evolutionof Risk and Risk Management P:117/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰConclusion and Discussion Risk4.0 = f (Changes in Circumstances) :
- 118. 201901 Concept Evolutionof Risk and Risk Management P:118/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰConclusion and Discussion Risk Manageme4.0 (Manage the Control System of the System) Model Building, Simulation and Reshape the System Dynamic and Mindset Suitable for new (project, factory, design) rather than existing (project, factory, design...)
- 119. 201901 Concept Evolutionof Risk and Risk Management P:119/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰConclusion and Discussion Risk Management 0.0~4.0 Is Co-existing and Complementary Is NOT Substitute nor Shift or Migrate 0.0 1.0 2.0 3.0 4.0 X O
- 120. 201901 Concept Evolutionof Risk and Risk Management P:120/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰConclusion and Discussion Causality and Determinism? People have free will and the world has unlimited possibilities Significant correlation Don’t mean causal relationship! Contributing factor is not a cause! Source: https://www.youtube.com/watch?v=dS_oAQmbD_I Causal relationship is just a perceived illusion ? !
- 121. 201901 Concept Evolutionof Risk and Risk Management P:121/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰConclusion and Discussion Destiny and Fatalism? Time-Space is a continuity (there is no future, present or past) The future and Destiny is existed (we just don’t know about it yet)
- 122. 201901 Concept Evolutionof Risk and Risk Management P:122/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Risk: Effect of Uncertainty Strategic Perspective Ǹ Effect is a deviation from the expected ȋ positive or negative. Risk = Opportunity Cost (side effect) to Do Something or Nothing Risk Management = Rate/Odds of Gain/Pros Rate/Odds of Loss/Cons Opportunity Cost: as the loss of potential gain from other alternatives when one alternative is chosen. Disaster and Catastrophe is accidental (unforeseen) side effect... ᙓ ࣙ (ᅿ)ӢǵΥ Γ ࣙ ݀(ൔ) RM 5.0? Risk is side effect, result of trade off and opportunity cost Conclusion and Discussion
- 123. 201901 Concept Evolutionof Risk and Risk Management P:123/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Risk Effect of Uncertainty Strategic Perspective Ǹ Effect is a deviation from the expected ȋ positive or negative. Risk = Opportunity Cost (side effect) to Do Something or Nothing Risk Management = Rate/Odds of Gain/Pros Rate/Odds of Loss/Cons Mindful Choice and Decision(ݙ ཀ ଆ Ј ۺ ᆶ ࣮ ό ـ ޑ ᐒ ԋ ҁ ж ሽ ), ᅾ ᅽ ࣬ ғ ࣬ ٩ (ന ٫ ϯ Ѝؒ Ԗ ᔈᡂ Ꭹ ျ Ѝو ᒳ শ Π ҂ ᛈ ቸ ) ᙓ ࣙ (ᅿ)ӢǵΥ Γ ࣙ ݀(ൔ)=ό ዴ ۓ ޑ ნ Π Ǵा Ԗ Ӽ ӄ Ꭹ ျ (ߥ Ӻ ) RM 5.0? Risk is side effect, result of trade off and opportunity cost System Completion Rate Schedule Delays Work Rate - + + Pressure to Deliver + Safety and Integration Priority - Resource Pressure Safety and Integration Resources - + + R1 Burnout Cycle B1 Burnout Rework Cycle R4 Accumulating Waivers R2 Delays cause Pressure Satisfaction of Funding Organization Burnout + - Quality and Timeliness of Safety and Integration Analyses - Design Tasks to be Reworked Unsatisfied Safety Requirements - Subtle Mistakes - System Lifecycle Cost - + + Operational Workarounds + Safety Rework Cycle R3 B/R 1 Resource Allocation B/R 2 Cost Overruns Conclusion and Discussion
- 124. 201901 Concept Evolutionof Risk and Risk Management P:124/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Risk Effect of Uncertainty Strategic Perspective Ǹ Effect is a deviation from the expected ȋ positive or negative. Risk = Opportunity Cost (side effect) to Do Something or Nothing Risk Management = Loss/Cons = Gain/Pros (а ௭ ඤ ள ) Mistake and Failure = Opportunity to Learn and Improve = Gain/Pros Error Trying=Opportunity/Competence Finding . ம ϯ ၮ բ ܄/ቚ у ޕ /ܗ س ၮ բ х ๎ य़ /ׯ ๓ ၮ բ ਏૈ RM 6.0 ? Risk is Opportunity to Learn, Improve Growth https://www.munichre.com/en/reinsurance/magazine/topic s-online/2017/topics-geo/resilience-overcoming-natural- disasters/index.html Conclusion and Discussion
- 125. 201901 Concept Evolutionof Risk and Risk Management P:125/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Resilience Is Cultivated from Failure/ Disorder ᅾ ᅽ ࣬ ғ ࣬ ٩ /༞ શ Ѩ ଭ ో ޕ ߚ ᅽ Source ൂ ߞ ྼ Lecture of Resilience Engineering Aspect of Resilience •The ability to prevent something bad from happening. •The ability to prevent something bad from becoming worse. •The ability to recover something bad once it has happened. RM 6.0 ? Risk is Opportunity to Learn, Improve Growth Conclusion and Discussion
- 126. 201901 Concept Evolutionof Risk and Risk Management P:126/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Risk Ѝ Destiny (Probability Distribution) Risk = Different Destiny for Do Something or Nothing at different moments as well Risk Management = Fortune Telling(ό ӕ చ ҹ ᆶ ಔ ᙃ ၮ բ ნ Π ޑ ว ڮ ၮ ) RM 7.0 ? Foresee the Future and Possibilities Conclusion and Discussion
- 127. 201901 Concept Evolutionof Risk and Risk Management P:127/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰᇡգԾρᇡգԾρᇡգԾρᇡգԾρEnd Look at the “machine ” (law/ organization/ system/ Accident…) from the higher level.
- 128. 201901 Concept Evolutionof Risk and Risk Management P:128/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ Hope for the Best, Prepare for the Worst Ј Ӹ ๓ ۺ /ᅰ Κ Զ ࣁ Aware, Accept, Adapt and Advance the System End ᖮ ϐ ॣ Ǻ TSMCབTriple A ӧ Π ග р AAAA
- 129. 201901 Concept Evolutionof Risk and Risk Management P:129/129 ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰᇡգԾρᇡգԾρᇡգԾρᇡգԾρEnd eshwayne@gmail.com Phone:0922516248 Life is Journey and Discipline PDSA: Look to the patterns of those things that affect you in order to understand the cause- effect relationships that drive them and to learn principles (natural law) for dealing with them effectively. ፏ Չ ค த ǵፏ ݤ ค ך )ܫ Π ך ᆶ Ӽ ӄ ޑ ଷ ຝ * ό ࢂ ό ပ Ӣ݀ Զ ࢂ ό ࢁ ܭ Ӣ݀(ܫ Π ୍ ၸ Ѩ ᆶ Ӣ݀ ፕ ޑ ୃ ـ )