Are all accidents preventable? Steve Woodward walks NOSHCON 2015 attendees through the seven delusions under which safety officials function, and challenges outdated, unsafe habits.
Human Factors Training: There's nothing that can't go wrong. This simple insight forms the foundation of human factors training for pilots. In special courses, pilots are prepared for any possible emergency situation and action strategies. Crews learn to analyze and evaluate their own behavior and that of those around them more effectively. Training leads to more efficient work processes, a functioning error management culture, and increased safety. This is a general prsentation and human factors management in aviation training.
In pharmaceutical industry any investigation is concluded with "Human error" as root cause then understanding needs to be built for the root cause analysis.
It is very easy to conclude as Human error, but difficult to justify.
These Presentation includes
1. Trend of Human error in various industries.
2. Facts and Finding on Human error
3. Definition of Human error.
4. Viewpoint "Human Error"
5. Understanding of Human error part-1 and 2.
6. Contributing factors for human error.
7. Human weaknesses.
8. Human limitations.
9. Let's Have part (Secret game zone)
10. Human error investigation
11. Human error reduction
12. Thank you note
Human Factors Training: There's nothing that can't go wrong. This simple insight forms the foundation of human factors training for pilots. In special courses, pilots are prepared for any possible emergency situation and action strategies. Crews learn to analyze and evaluate their own behavior and that of those around them more effectively. Training leads to more efficient work processes, a functioning error management culture, and increased safety. This is a general prsentation and human factors management in aviation training.
In pharmaceutical industry any investigation is concluded with "Human error" as root cause then understanding needs to be built for the root cause analysis.
It is very easy to conclude as Human error, but difficult to justify.
These Presentation includes
1. Trend of Human error in various industries.
2. Facts and Finding on Human error
3. Definition of Human error.
4. Viewpoint "Human Error"
5. Understanding of Human error part-1 and 2.
6. Contributing factors for human error.
7. Human weaknesses.
8. Human limitations.
9. Let's Have part (Secret game zone)
10. Human error investigation
11. Human error reduction
12. Thank you note
PSD Operational Risk Event - June 2016 PSD Group Ltd
PSD's Banking & Financial Services sector recently hosted a forum to explore risk management in smaller banking firms.
Dr Ariane Chapelle, Director of Chapelle Consulting, was the key note speaker, giving a thought provoking presentation.
How can you prepare your company to avoid unnecessary losses? Experts in the insurance, safety and risk management arena will provide detailed industry-specific information that you can begin using right away to protect your company and its financial health for years to come. You’ll leave this session with a clear understanding of why loss prevention is as essential for survival as regulatory compliance.
Speakers:
Kent Miller, Field Supervisor, Safety, Claims and Litigation Services (SCLS)
Dave Wittwer, Vice President, Hays Companies
Risk management is a strategic security activity and is a cornerstone of security governance. The management of risk not only requires that we effectively measure it but also understand what effect vulnerability has on the level of risk. Both risk and vulnerability constantly change and not only in response to threats but also business initiatives. Does your organization have a mature risk and vulnerability identification, measurement and management process? The discussion will identify how risk responds to changes in vulnerability and how we might maximize our risk management activities to enhance the resilience of the organization and its assets.
Presentation by: Philip Banks, P. Eng., CPP, Director, The Banks Group
Conference presentation. What cognitive biases affect the way we think about risk? How does an Agile approach help to manage risk and what tactical practices can you apply?
Introduction to Operational Risk Management for Bank Junior Officers in IndiaVenkataraman Mudaliar M L
This is an introductory, self-explanatory presentation on Operational Risk Management for Junior officers in Banks, illustrated with lots of interesting images to make the concepts easy to understand. Follow the link at the end of the slides to read interesting Op Risk stories compiled from day to day banking, which can be used for group exercise or better personal understanding. (Answers are not given! You have to generate them yourselves or from team members ! ).
(The story on Corporate Banking may appear similar to the recent Banking scam - Feb 2018 - in India, but then, similar frauds have been repeatedly happening in one Bank or the other in the last 3 decades in India. Neither Banks nor RBI appear to have learnt the operational risk lessons).
You are free to use the slides and my stories for your work.
I acknowledge and thank Internet and all original creators for providing cartoons, illustrations, photos, jokes and information which I have liberally used in the PPT.
Introduction to Operational Risk Management for Bank Junior Officers in Indiamlvenkat
This is an introductory, self-explanatory presentation on Operational Risk Management for Junior officers in Banks in India, illustrated with lots of interesting images to make the concepts easy to understand. Follow the link at the end of the slides to read interesting Op Risk stories compiled from day to day banking, which can be used for group exercise or better personal understanding. (Answers are not given! You have to generate them yourselves or from team members ! ).
(The story on Corporate Banking may appear similar to the recent Banking scam -Feb 2018- in India, but then, similar frauds have been repeatedly happening in one Bank or the other in the last 30 years in India. Neither Commercial Banks in India nor Reserve Bank of India have learnt the operational risk lessons).
You are free to use the slides and my stories for your work.
You can customise the stories to suit your banking environment and/or to add your own Bank stories to build up a library of Op Risk events.
I acknowledge and thank Internet and all original creators for providing cartoons, illustrations, photos, jokes and information which I have liberally used in the PPT.
This complete presentation has a set of thirty two slides to show your mastery of the subject. Use this ready-made PowerPoint presentation to present before your internal teams or the audience. All presentation designs in this Risk Analysis PowerPoint Presentation Slides have been crafted by our team of expert PowerPoint designers using the best of PPT templates, images, data-driven graphs and vector icons. The content has been well-researched by our team of business researchers. The biggest advantage of downloading this deck is that it is fully editable in PowerPoint. You can change the colors, font and text without any hassle to suit your business needs.
The effectiveness of risk management depends on the people who set it up and coordinate the risk management process to do their job properly.
On many programs, risk management consists only of having a policy and oversight, not managing in the presence of uncertainty.
If we treat red flags as false alarms rather than early warnings of danger this incubates the threats to program success.
• Group think of dominate leaders often inhibits good thinking about risks.
Enhance your audiences knowledge with this well researched complete deck. Showcase all the important features of the deck with perfect visuals. This deck comprises of total of thirty one slides with each slide explained in detail. Each template comprises of professional diagrams and layouts. Our professional PowerPoint experts have also included icons, graphs and charts for your convenience. All you have to do is DOWNLOAD the deck. Make changes as per the requirement. Yes, these PPT slides are completely customizable. Edit the colour, text and font size. Add or delete the content from the slide. And leave your audience awestruck with the professionally designed Risk Identification Powerpoint Presentation Slides complete deck.
How to be Wrong (or How to be Successful at Being Wrong)Russell Miles
In this talk Russ Miles, CEO at ChaosIQ, explores how to turn "Being Wrong" into a super-power through establishing a Resilience Engineering Capability that practices Chaos Engineering.
BLOQUE: SEGURIDAD MINERA
Conferencia magistral
Paulo Henrique Humberto Rheinbolt
Process and Industrial Safety Consultant
Det Norske Veritas Business Assurance Brazil
Jueves 19 de setiembre, 2013
Risk Assessment And Mitigation Plan PowerPoint Presentation SlidesSlideTeam
This deck consists of total of thirty three slides. It has PPT slides highlighting important topics of Risk Assessment And Mitigation Plan Powerpoint Presentation Slides. This deck comprises of amazing visuals with thoroughly researched content. Each template is well crafted and designed by our PowerPoint experts. Our designers have included all the necessary PowerPoint layouts in this deck. From icons to graphs, this PPT deck has it all. The best part is that these templates are easily customizable. Just click the DOWNLOAD button shown below. Edit the colour, text, font size, add or delete the content as per the requirement. Download this deck now and engage your audience with this ready made presentation.
NOSA’s very own Head of Innovation, Dr Deonie Botha, deliberated the fact that the business environment is complex in nature and that organisations need to function like complex adaptive systems to be robust and ensure long-term sustainability. ISO 45001 emphasises a multitude of technical and non-technical factors, which organisations need to manage in order to ensure compliance. However, Deonie also highlighted how it will also serve as a tool to assist organisations in being robust and ensuring sustainability.
In one of the hottest topics in current health and safety trends, George Coetzee outlined the methodology to follow when using bowtie risk analysis, and the practical application of ‘barrier’ thinking to understand the complexity of how material unwanted events (MUEs) materialise and how to determine pathway vulnerability. The methodology also described a systematic approach to develop an effective critical control framework to prevent MUEs from materialising.
More Related Content
Similar to Accident Investigations - Blame and Shame or Listen and Learn?
PSD Operational Risk Event - June 2016 PSD Group Ltd
PSD's Banking & Financial Services sector recently hosted a forum to explore risk management in smaller banking firms.
Dr Ariane Chapelle, Director of Chapelle Consulting, was the key note speaker, giving a thought provoking presentation.
How can you prepare your company to avoid unnecessary losses? Experts in the insurance, safety and risk management arena will provide detailed industry-specific information that you can begin using right away to protect your company and its financial health for years to come. You’ll leave this session with a clear understanding of why loss prevention is as essential for survival as regulatory compliance.
Speakers:
Kent Miller, Field Supervisor, Safety, Claims and Litigation Services (SCLS)
Dave Wittwer, Vice President, Hays Companies
Risk management is a strategic security activity and is a cornerstone of security governance. The management of risk not only requires that we effectively measure it but also understand what effect vulnerability has on the level of risk. Both risk and vulnerability constantly change and not only in response to threats but also business initiatives. Does your organization have a mature risk and vulnerability identification, measurement and management process? The discussion will identify how risk responds to changes in vulnerability and how we might maximize our risk management activities to enhance the resilience of the organization and its assets.
Presentation by: Philip Banks, P. Eng., CPP, Director, The Banks Group
Conference presentation. What cognitive biases affect the way we think about risk? How does an Agile approach help to manage risk and what tactical practices can you apply?
Introduction to Operational Risk Management for Bank Junior Officers in IndiaVenkataraman Mudaliar M L
This is an introductory, self-explanatory presentation on Operational Risk Management for Junior officers in Banks, illustrated with lots of interesting images to make the concepts easy to understand. Follow the link at the end of the slides to read interesting Op Risk stories compiled from day to day banking, which can be used for group exercise or better personal understanding. (Answers are not given! You have to generate them yourselves or from team members ! ).
(The story on Corporate Banking may appear similar to the recent Banking scam - Feb 2018 - in India, but then, similar frauds have been repeatedly happening in one Bank or the other in the last 3 decades in India. Neither Banks nor RBI appear to have learnt the operational risk lessons).
You are free to use the slides and my stories for your work.
I acknowledge and thank Internet and all original creators for providing cartoons, illustrations, photos, jokes and information which I have liberally used in the PPT.
Introduction to Operational Risk Management for Bank Junior Officers in Indiamlvenkat
This is an introductory, self-explanatory presentation on Operational Risk Management for Junior officers in Banks in India, illustrated with lots of interesting images to make the concepts easy to understand. Follow the link at the end of the slides to read interesting Op Risk stories compiled from day to day banking, which can be used for group exercise or better personal understanding. (Answers are not given! You have to generate them yourselves or from team members ! ).
(The story on Corporate Banking may appear similar to the recent Banking scam -Feb 2018- in India, but then, similar frauds have been repeatedly happening in one Bank or the other in the last 30 years in India. Neither Commercial Banks in India nor Reserve Bank of India have learnt the operational risk lessons).
You are free to use the slides and my stories for your work.
You can customise the stories to suit your banking environment and/or to add your own Bank stories to build up a library of Op Risk events.
I acknowledge and thank Internet and all original creators for providing cartoons, illustrations, photos, jokes and information which I have liberally used in the PPT.
This complete presentation has a set of thirty two slides to show your mastery of the subject. Use this ready-made PowerPoint presentation to present before your internal teams or the audience. All presentation designs in this Risk Analysis PowerPoint Presentation Slides have been crafted by our team of expert PowerPoint designers using the best of PPT templates, images, data-driven graphs and vector icons. The content has been well-researched by our team of business researchers. The biggest advantage of downloading this deck is that it is fully editable in PowerPoint. You can change the colors, font and text without any hassle to suit your business needs.
The effectiveness of risk management depends on the people who set it up and coordinate the risk management process to do their job properly.
On many programs, risk management consists only of having a policy and oversight, not managing in the presence of uncertainty.
If we treat red flags as false alarms rather than early warnings of danger this incubates the threats to program success.
• Group think of dominate leaders often inhibits good thinking about risks.
Enhance your audiences knowledge with this well researched complete deck. Showcase all the important features of the deck with perfect visuals. This deck comprises of total of thirty one slides with each slide explained in detail. Each template comprises of professional diagrams and layouts. Our professional PowerPoint experts have also included icons, graphs and charts for your convenience. All you have to do is DOWNLOAD the deck. Make changes as per the requirement. Yes, these PPT slides are completely customizable. Edit the colour, text and font size. Add or delete the content from the slide. And leave your audience awestruck with the professionally designed Risk Identification Powerpoint Presentation Slides complete deck.
How to be Wrong (or How to be Successful at Being Wrong)Russell Miles
In this talk Russ Miles, CEO at ChaosIQ, explores how to turn "Being Wrong" into a super-power through establishing a Resilience Engineering Capability that practices Chaos Engineering.
BLOQUE: SEGURIDAD MINERA
Conferencia magistral
Paulo Henrique Humberto Rheinbolt
Process and Industrial Safety Consultant
Det Norske Veritas Business Assurance Brazil
Jueves 19 de setiembre, 2013
Risk Assessment And Mitigation Plan PowerPoint Presentation SlidesSlideTeam
This deck consists of total of thirty three slides. It has PPT slides highlighting important topics of Risk Assessment And Mitigation Plan Powerpoint Presentation Slides. This deck comprises of amazing visuals with thoroughly researched content. Each template is well crafted and designed by our PowerPoint experts. Our designers have included all the necessary PowerPoint layouts in this deck. From icons to graphs, this PPT deck has it all. The best part is that these templates are easily customizable. Just click the DOWNLOAD button shown below. Edit the colour, text, font size, add or delete the content as per the requirement. Download this deck now and engage your audience with this ready made presentation.
Similar to Accident Investigations - Blame and Shame or Listen and Learn? (20)
NOSA’s very own Head of Innovation, Dr Deonie Botha, deliberated the fact that the business environment is complex in nature and that organisations need to function like complex adaptive systems to be robust and ensure long-term sustainability. ISO 45001 emphasises a multitude of technical and non-technical factors, which organisations need to manage in order to ensure compliance. However, Deonie also highlighted how it will also serve as a tool to assist organisations in being robust and ensuring sustainability.
In one of the hottest topics in current health and safety trends, George Coetzee outlined the methodology to follow when using bowtie risk analysis, and the practical application of ‘barrier’ thinking to understand the complexity of how material unwanted events (MUEs) materialise and how to determine pathway vulnerability. The methodology also described a systematic approach to develop an effective critical control framework to prevent MUEs from materialising.
Were you aware that at least 3.5 million South Africans have been diagnosed with diabetes? About 200 million people worldwide have metabolic syndrome (diabetes, insulin resistance, high blood pressure, obesity, and high cholesterol). Dr Arien Van der Merwe shared important information on how to screen for, diagnose and manage this prevalent health challenge.
Dr Eugene Kemp rethinks HSE leadership within the current global context and helps you understand the unique challenges the next decade is likely to present. Attendees had the opportunity to understand current trends and equip themselves with the resilience skills to bounce back from disruption – and initiate innovation.
Johann Havenga: Wearable Technology in Support of Health, Wellness and WellbeingSAMTRAC International
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About the Speaker
===============
Diogo Sousa, Engineering Manager @ Canonical
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Accident Investigations - Blame and Shame or Listen and Learn?
1. Deepwater
Horizon
Delusions
Delusion
of
preventability
and
lineraity
Examples
of
all
accidents
are
preventable
–
lucky,
Chemical
factory
Lac
MeganBc
Typical
accident
analysis
–
RCM
steps
Human
error
Killer
Driver
Human
capability
–
ball
girl,
baseball
player,
The
Accident
Just
culture
repsonses
AlternaBve
methods
Leadership
link
2. “Blame
‘n
shame”
or
‘Listen
and
Learn”
A
Just
approach
to
Accident
InvesBgaBon
NOSHCON
September
2015
PresentaBon
by
Steve
Woodward
–
SAFEmap
InternaBonal
3. All accidents are preventable!!
If
we
know
the
effect
we
can
determine
the
cause
If
we
know
the
cause
we
can
eliminate
it
From
this
mindset
it
follows
that….
We
should
never
have
an
accident
so
why
do
we
…well
human
error
of
course..
10. Analyze
and
prevent
accidents
Eliminate
risk-‐taking
Enforce
safety
rules
Educate
in
safe
work
procedures
Engineer
a
safe
work
environment
Measure
safety
performance
Reward
achievements
12. 1. The
delusion
of
causa=on
2. preventability
2.
The
delusion
of
human
error
3.
The
delusion
of
compliance
4.
The
delusion
of
consistency
5.
The
delusion
of
control
6.
The
delusion
of
quan=fica=on
7.
The
delusion
of
invulnerability
24. Driver
Change
over
Thin
tanker
shells
fail
Air
release
Fire
fighters
shuts
loco
911
call:
Loco
fire
All
leave
scene
No
loco
started
Hand
brakes
fail
Parked
on
.92%
gradient
Sets
7
handbrakes
Reports
smoke
to
authority
32. Average
level
of
posi=ve
responses“All accidents can be prevented”
0
0
20
30
40
50
60
70
Percent Agree Linear (Percent Agree)
More positive companies
Best safety performance
More negative companies
Worst safety performance
38. 1.
The
delusion
of
causa=on
2.
The
delusion
of
human
error
3.
The
delusion
of
compliance
4.
The
delusion
of
consistency
5.
The
delusion
of
control
6.
The
delusion
of
quanBficaBon
7.
The
delusion
of
invulnerability
48. TradiBonal
View
of
Determining
Incident
Causes
Substandard
Acts
Substandard
CondiBons
Personal
Factors
Job
Factors
Incident
Immediate
Causes
Underlying
or
Root
Causes
Management
System
Deficiencies
Incident
Causa=on
Path
Incident
Inves=ga=on
Path
No
Standard,
Inadequate
Standard,
Non-‐Compliance
“Finding
the
management
system
deficiencies
that
led
to
the
incident”
49.
50. Evolving
View
of
Determining
Incident
Causes
Incident
Substandard
Acts
Substandard
CondiBons
Immediate
Causes
Human
Factors
Systemic
Factors
ContribuBng
Factors
Management
System
Deficiencies
No
Standard,
Inadequate
Standard,
Non-‐Compliance
Incident
Causa=on
Path
Incident
Inves=ga=on
Path
“Finding
the
management
system
deficiencies
that
led
to
the
incident”
Physical
Factors
53. Inves=ga=on
Risk
Calculator
Exercises
• For
each
example
provided,
determine
the
following:
a) The
Actual
risk
level
and
PotenBal
risk
level;
b) The
recommended
team
size
(supervisor
only,
small
team
or
full
team);
and,
c) The
report
type
(limited
invesBgaBon
or
a
full
invesBgaBon
report)
54.
55. "Ladies
and
gentlemen,
thank
you
for
flying
with
our
Airline.
Please
make
yourself
comfortable..…
For
those
of
you
si?ng
on
the
right
side
of
the
plane..…
please
ignore
our
other
airliner."
A
Cabin
Announcement:
56.
57. Anchor Error
! Severe accidents are overestimated
− For example: nuclear, sharks, guns
68. 1.
The
delusion
of
linearity
2.
The
delusion
of
human
error
3.
The
delusion
of
compliance
4.
The
delusion
of
consistency
5.
The
delusion
of
control
6.
The
delusion
of
quanBficaBon
7.
The
delusion
of
invulnerability
69.
70.
71.
72. As humans, we can (uniquely) be:
! Ina_enBve
! Incompetent
! ErraBc
! Biased
! ViolaBng
• Lapsing
• Forgetful
• Unreliable
• Inconsistent
• Rigid
and
complacent...!
73. As humans, we can (uniquely) be:
• Enduring
• Compassionate
• ImaginaBve
• Sacrificing
• Conquering
• Heroic
• Passionate
• Inspirational
• Intuitive
• Adaptive
