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The Keys to a Successful Systemic Approach to Risk Management

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Navigating Safety

Part of the book series: SpringerBriefs in Applied Sciences and Technology ((BRIEFSAPPLSCIENCES))

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Abstract

It is universally admitted that an approach to safety applied to our complex industries (nuclear, chemical, construction and skilled trades) and services (medicine, banking and finance, public and private transport), can no longer be limited to finding local technical solutions; it absolutely must be systemic and global. How should these concepts be fleshed out? This chapter seeks to answer this question from various different perspectives, using examples taken from many contrasting areas, breaking down bias and prejudice and offering practical keys.

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Notes

  1. 1.

    This criticism is debated particularly effectively in Hollnagel et al. [4].

  2. 2.

    This criticism is discussed particularly well in Dekker [5].

  3. 3.

    Search of Google and (review summaries) in December 2011, limited to eight journals: Human factors, Safety Science, Ergonomics, Accident analysis and Prevention, Journal of Safety research, Journal of Risk research, International Journal Quality in Health Care, British Medical Journal Quality and Safety.

  4. 4.

    Numerous references exist on this subject, most of them dating back some time. Many different summaries exist on a number of websites (although this list is not exclusive) http://pachome1.pacific.net.sg/~thk/risk.html accessed on 27 décembre 2011 http://www.statcart.com/ viewed on 27 December 2011or the remarkable summary with reference to the medical field, which was published in French in five articles by a group of authors, specifically [7, 8].

  5. 5.

    Obstacles to participation: the top 9 reasons why workers don’t report near misses, 2011, http://ehstoday.com/safety/news/9-reasons-near-miss-reporting/.

  6. 6.

    Danish act on patient safety, http://www.patientsikkerhed.dk/admin/media/pdf/133907d0940e4d5f751852ec8f6b1795.pdf.

  7. 7.

    US patient safety and quality improvement act, 2005, http://www.ahrq.gov/qual/psoact.htm.

  8. 8.

    http://asrs.arc.nasa.gov/overview/immunity.html#, accessed on 26 December 2011.

  9. 9.

    A good summary of this debate is found in Dekker [24].

  10. 10.

    http://www.iata.org/ps/intelligence_statistics/pages/fda.aspx.

  11. 11.

    In the area of production line quality, decision-making methods tend to be used that give priority to frequency (the Pareto method is the best known of these).

  12. 12.

    Ostberg [31] RISCResearch Paper No. 3, http://www.wisdom.at/Publikation/pdf/RiskBerichte/RRR_GOestberg_SomeIntangibles_09.pdf.

  13. 13.

    Wilson [43], or http://mullerlbl.gov/teaching/physics10/old%20physics%2010/physics%2010%20notes/Risk.html.

  14. 14.

    deMontmollin M. L’ergonomie de la tâche, Peter Lang, Berne, 1986.

  15. 15.

    The case of fighter pilots is a special and interesting case of a dual context: in peacetime, their administration (the Air Force) operates essentially on an ultra-safe model, but once the aircraft are deployed on active service, the operating model suddenly changes and returns to its fundamentals of resilience. These very contrasting contexts do generate surprises in terms of safety in both directions: persistence of resilient, deviant behaviour (as compared with the model that would be desired in peacetime) after returning from military campaigns, and important opportunities that are missed during the first few days of engagement due to lack of practice in the resilient model, when pilots are suddenly thrust from peacetime into operational theatres. A military air force can also shift the crew of an AWACS surveillance aircraft from peacetime into wartime during the space of a single mission: they may leave a French base in France, having dropped their children off at school in the morning… fly a 12 h mission that involves working in and overflying an operational theatre with a very high risk of aerial engagement and requiring particularly high resilience and return the following night to their air force base in France and also to their homes, which are completely organised around social routines and the challenges of peacetime.

  16. 16.

    The rate of fatal accidents in professional deep-sea fishing varies by a factor of 4 between ship owners in France and by a factor of 9 at the global level, source: Morel et al. [52], op. cit.

  17. 17.

    The rate of fatal industrial accidents in the gas and oil extraction industry varies from 130 deaths per 100,000 workers in some African countries to 12 deaths per 100,000 workers for the best oil wells; the global average is 30.5 deaths per 100,000 workers, source: http://nextbigfuture.com/2011/03/oil-and-gas-extraction-accidents-and.html.

  18. 18.

    The rate of aviation accidents ranges from 0.63 per million departures in Western countries to 7.41 per million departures in African countries. These therefore differ by a factor of 12, source: IATA statistics, 23 February 2011, http://www.iata.org/pressroom/pr/pages/2011-02-23-01.aspx.

  19. 19.

    The unexpected being referred to here is not the surprise of a logged breakdown occurring for which a procedure exists. Of course breakdowns and problems are not reported in advance, but they form an integral part of the ultra-safe model, with operators who are trained to respond. We are talking here about situations that have never been encountered before and for which no written procedures exist. It would therefore be necessary to improvise.

  20. 20.

    This safety level of 106 is the guaranteed level for risk analyses at the design stage for the aviation and nuclear industries.

  21. 21.

    Middle managers are managers who work at an intermediate level in the hierarchy, between the executive level and front-line managers; they typically run a functional unit, source Uyterhoeven [54], Thakur [55].

  22. 22.

    ICSI, Leadership en sécurité, Cahiers de la sécurité industrielle, accessed on 29 December at http://www.icsi-eu.org/francais/dev_cs/cahiers/CSI-LIS-pratiques-industrielles.pdf.

  23. 23.

    Daniellou F, Simart M, Boissière I. Human and organizational factors of safety: state of the art, ICSI, http://www.foncsi.org/media/PDF/CSI-HOFS.pdf.

  24. 24.

    A good summary of this whole approach in Braithwaite et al. [72].

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  1. Haute Autorité de Santé, Avenue du Stade de France 2, 93218, Saint Denis-La Plaine, France

    René Amalberti

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Amalberti, R. (2013). The Keys to a Successful Systemic Approach to Risk Management. In: Navigating Safety. SpringerBriefs in Applied Sciences and Technology. Springer, Dordrecht. https://doi.org/10.1007/978-94-007-6549-8_3

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