Accident Precursor Analysis and Management Reducing Technological Risk Through Diligence (2004) / Chapter Skim
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11 Stuck on a Plateau: A Common Problem
11 Stuck on a Plateau: A Common Problem
Pages 147-154
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From page 147... ...
In the course of developing GAIN, the Of lice of System Safety noted that many other industries have also experienced a leveling off of mishap rates. These industries include other transportation industries, health care, national security, chemical manufacturing, public utilities, information infrast ucture protection, and nuclear power.
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From page 148... ...
In systems with robust defenses against mishaps, the characteristic confgurahon of incidents and accidents cam be depicted by a Heinnch pyramid (Figure 2) , which shows that, for every fatal accident, there will be three to five nonfatal accidents and 10 told incidents; but there will also be hundreds of unreported occurrences (the exact ratios vary)
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From page 149... ...
In most mdustries, including aviation, most of the mformation necessary for identifymg precursors and addressing them is likely to be m the large part of dhe pyramid. Legged Deterrents to Reporting In the United States, four factors have discouraged frontline workers, whose voluntary teporpmg is most i nportant, from cotrnng forth wish mformation.
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From page 150... ...
Analytical Tools Once the legal issues have been addressed, most indushies face an even more significant obstacle the lack of sophisticated analytical tools that can "separate sparse quantities of gold from large qmmtities of gravel" a.e., convert large quantities of data into useful information)
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From page 151... ...
be systematically collected and amalyzed so that analysts c m learn more about their causes and develop remedies to prevent or elimmate them. The premise of dhis proactive approach is described as follows: Preventing errors means designing the health care system at all levels to make it safer.
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From page 152... ...
Labor wins because, instead of takmg the brunt of the blame and the punishment, ftontline employees become valuable sources of mformation about potential problems and proposed solutions to accomplish what everyone wants fewer mishaps. Government regulators wan because the better they underst~md problems, the smarter they can be about proposmg effective, credible remedies.
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From page 153... ...
CONCLUSION Many industries, including most transpo tation industries, health care, national security, chemical manufacturing, public utilities, information infrast ucture protection, and nuclear power, have experienced a levelmg off of the rate of mishaps. They are now considering adapting proactive infonnarion-gathering programs to identify mishap precursors and remedy them m m effort to lower the rate of mishaps further.
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From page 154... ...
2003. Staostical Sttmmary of Commercial Jet Aimlane Accidems, Worldwide Opetanons, 1959 2002.
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