How tin industries involving processes that create large risks of harm for individuals or populations move modified then they are to a g...
How tin industries involving processes that create large risks of harm for individuals or populations move modified then they are to a greater extent than capable of detecting too eliminating the precursors of harmful accidents? How tin nuclear accidents, aviation crashes, chemic flora explosions, too medical errors move reduced, given that each of these activities involves large bureaucratic organizations conducting complex operations too alongside substantial inter-system linkages? How tin organizations move reformed to heighten security too to minimize the likelihood of harmful accidents?
One of the lessons learned from the Challenger infinite shuttle disaster is the importance of a strongly empowered security officeholder inwards organizations that bargain inwards high-risk activities. This agency the creation of a seat dedicated to ensuring security operations that falls exterior the normal chain of command. The thought is that the normal decision-making hierarchy of a large organisation has a built-in vogue to keep production schedules too avoid costly delays. In other words, at that topographic point is a built-in incentive to care for security issues alongside lower priority than most people would expect.
If at that topographic point had been an empowered security officeholder inwards the launch hierarchy for the Challenger launch inwards 1986, at that topographic point is a goodness take away chances this officeholder would accept listened to a greater extent than carefully to the Morton-Thiokol engineering team's concerns most cold impairment to O-rings too would accept ordered a halt to the launch sequence until temperatures inwards Florida raised to the critical value. The Rogers Commission faulted the decision-making physical care for leading to the launch determination inwards its concluding written report on the accident (The Report of the Presidential Commission on the Space Shuttle Challenger Accident - The Tragedy of Mission 51-L inwards 1986 - Volume One, Volume Two, Volume Three).
This approach is productive because empowering a security officeholder creates a unlike fix of interests inwards the management of a risky process. The security officer's involvement is inwards safety, whereas other determination makers are concerned most revenues too costs, world relations, reputation, too other instrumental goods. So a dedicated security officeholder is empowered to elevate security concerns that other officers mightiness move hesitant to raise. Ordinary bureaucratic incentives may atomic number 82 to underestimating risks or concealing faults; then lowering the accident charge per unit of measurement requires giving some individuals the incentive too ability to human activity effectively to bring down risks.
Similar findings accept emerged inwards the study of medical too infirmary errors. It has been recognized that high-risk activities are made less risky past times empowering all members of the squad to telephone telephone a halt inwards an activity when they perceive a security issue. When all members of the surgical squad are empowered to halt a physical care for when they greenback an apparent error, serious operating-room errors are reduced. (Here is a written report from the American College of Obstetricians too Gynecologists on surgical patient safety; link. And hither is a 1999 National Academy written report on medical error; link.)
The effectiveness of a team-based approach to security depends on 1 key fact. There is a high score of expertise embodied inwards the staff operating a surgical suite, an engineering laboratory, or a drug manufacturing facility. By empowering these individuals to halt a physical care for when they guess at that topographic point is an unrecognized mistake inwards play, this greatly extend the amount of embodied cognition involved inwards a process. The surgeon, the commanding officer, or the lab manager is no longer the sole proficient whose judgments count.
But it besides seems clear that these innovations don't move as good inwards all circumstances. Take nuclear ability flora operations. In Atomic Accidents: Influenza A virus subtype H5N1 History of Nuclear Meltdowns too Disasters: From the Ozark Mountains to Fukushima James Mahaffey documents multiple examples of nuclear accidents that resulted from the efforts of mid-level workers to address an emerging occupation inwards an improvised way. In the instance of nuclear ability flora safety, it appears that the best prescription for security is to insist on stiff adherence to pre-established protocols. In this instance the business office of a security officeholder is to monitor operations to ensure protocol conformance -- non to exercise independent judgment most the best way to response to an unfavorable reactor event.
It is inwards fact an interesting exercise to seek to seat the kinds of operations inwards which these innovations are probable to move effective.
Here is a fascinating interview inwards Slate alongside Jim Bagian, a quondam astronaut, one-time director of the Veteran Administration's National Center for Patient Safety, too distinguished security expert; link. Bagian emphasizes the importance of taking a system-based approach to safety. Rather than focusing on finding blame for specific individuals whose actions led to an accident, Bagian emphasizes the importance of tracing dorsum to the institutional, organizational, or logistic background of the accident. What tin move changed inwards the physical care for -- of delivering medications to patients, of fueling a rocket, or of moving nuclear solutions closed to inwards a laboratory -- that brand the likelihood of an accident substantially lower? (Here is a co-authored slice past times Bagian too others on the topic of team-based patient security inwards the operating room; link.)
The security principles involved hither seem fairly simple: cultivate a civilisation inwards which errors too near-misses are reported too investigated without blame; empower individuals inside risky processes to halt the physical care for if their expertise too sense indicates the possibility of a pregnant risky error; create individuals inside organizations whose interests are defined inwards price of the identification too resolution of dangerous practices or conditions; too part information most security inside the manufacture too alongside the public.
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