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Risk Management &  Human Error “ For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.   ”   –  Richard P. Feynman   Report of the Presidential Commission on the Space Shuttle Challenger Accident © 2002 EPL-Institute
Agenda ,[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Part1 , Introduction to Risk Management  © 2002 EPL-Institute
Agenda-Part1 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Important Definitions ,[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Risk Concepts  ,[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Risk Concepts part2 © 2002 EPL-Institute
There are only four ways of dealing with risk ,[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Ethics ,[object Object],[object Object],[object Object],© 2002 EPL-Institute
Risk Management ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Why perform RM ,[object Object],[object Object],[object Object],© 2002 EPL-Institute
Common myths about RM ,[object Object],[object Object],[object Object],© 2002 EPL-Institute
Too complex,costs too much or not needed? ,[object Object],[object Object],© 2002 EPL-Institute
The many uses of RM ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
History of Risk Management ,[object Object],[object Object],[object Object],© 2002 EPL-Institute
Who does RM ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Part 2 , components and processes © 2002 EPL-Institute
Agenda-Part2 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Components of Risk Management © 2002 EPL-Institute Risk Management consists of several components: Process Control Hazard Analysis Risk Assessment Risk Mitigation Fault Collection
Process Control ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Hazard Analysis ,[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Domains of Hazard Analysis ,[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Steps in Hazard Analysis © 2002 EPL-Institute
Finding Hazards – performing a Preliminary Hazard Analysis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute Performing a PHA is more of an ART than SCIENCE.  But remember that the foundation of success is cemented at this level!
Describing Hazards – think  Source / Mechanism / Outcome ,[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Expected Status Quo (2) ,[object Object],[object Object],© 2002 EPL-Institute
Hazard description example 1 ,[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Hazard Description assignment1. ,[object Object],[object Object],© 2002 EPL-Institute
Hazard Description assignment2. ,[object Object],[object Object],© 2002 EPL-Institute
Hazard Description Assigment 3 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Risk Assessment with Risk Matrix ,[object Object],[object Object],© 2002 EPL-Institute
Severity/Probability interpretations © 2002 EPL-Institute
Risk Assessment pointers ,[object Object],[object Object],© 2002 EPL-Institute
Risk Assessment is highly subjective ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Calibration of the Risk Matrix ,[object Object],[object Object],[object Object],© 2002 EPL-Institute Calibration Scenario:  Risk of commuting to/from work 20km/day on highly trafficked roads with speeds over 90km/h with rain and ice during wintertime. This is clearly I-Catastrophic since people die in traffic. Probability is clearly not F-Impossible but it is not D-Remote where specific permit must be gained before you are allowed to take your trip.  But if the Risk where to happen more often than today countermeasures would be implemented to minimize the risk. I/E
Some probability data ... ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Risk Mitigation ,[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Effectivness of Countermeasures ,[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute INCREASING EFFECTIVENESS
Revising Hazard Analysis/Risk Assessment ,[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Collecting Faults ,[object Object],[object Object],[object Object],© 2002 EPL-Institute
Disaster Planning ,[object Object],[object Object],© 2002 EPL-Institute
Example of Risk Management Process © 2002 EPL-Institute Risk Mitigation Risk Analysis Process Control / Fault Collection Develop  Controls & Make  Risk Decision Assess Hazards Supervise & Evaluate Identify Hazards Implement Controls
© 2002 EPL-Institute The objective is to identify hazards that may cause accidents.  Step 1: Identify Hazards Develop  Controls & Make  Risk Decision Identify Hazards Assess Hazards Supervise & Evaluate Implement Controls
© 2002 EPL-Institute Assess hazards to determine risks. Assess the impact of each hazard in terms of potential for loss,  based on probability and severity Develop  Controls & Make  Risk Decision Identify Hazards Assess Hazards Supervise & Evaluate Step 2: Assess Hazards Implement Controls Identify Hazards
© 2002 EPL-Institute Develop control measures that  eliminate the hazard or reduce its risk to an acceptable level   Implement Controls Develop  Controls & Make  Risk Decision Assess Hazards Supervise & Evaluate Step 3: Develop Controls &  Make Decision Identify Hazards
© 2002 EPL-Institute Take action to put the controls in place that eliminate the hazards or reduce their risks Step 4: Implement Controls Implement Controls Develop  Controls & Make  Risk Decision Assess Hazards Supervise & Evaluate Identify Hazards
© 2002 EPL-Institute Perform to, and enforce standards and controls. Evaluate the effectiveness of controls and adjust/ update as necessary  Develop  Controls & Make  Risk Decision Assess Hazards Supervise & Evaluate Step 5: Supervise & Evaluate Identify Hazards Implement Controls
Part 3 – Traps and common mistakes in Risk Management © 2002 EPL-Institute
Expected Status Quo ,[object Object],© 2002 EPL-Institute
Expected Status Quo (3) ,[object Object],[object Object],© 2002 EPL-Institute
Expected Status Quo (4) ,[object Object],© 2002 EPL-Institute
Individuals and RM ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Individuals and RM – Overconfidence ,[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Individuals and RM – Overconfidence2 ,[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Individuals and RM – confirmation bias ,[object Object],[object Object],[object Object],© 2002 EPL-Institute
Individuals and RM – Gamblers fallacy or  chance has no memory. ,[object Object],[object Object],© 2002 EPL-Institute
Individuals and RM - Anchoring ,[object Object],[object Object],© 2002 EPL-Institute
Individuals and RM – out of sight out of mind. ,[object Object],[object Object],[object Object],© 2002 EPL-Institute
Individuals and RM – workspace limitation – problem presentation ,[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Individuals and RM – Biased Reviewing ,[object Object],[object Object],[object Object],© 2002 EPL-Institute
Individuals and RM – Illusory correlation ( chapman & chapman, 1967 ) ,[object Object],© 2002 EPL-Institute
Individuals and RM – Halo Effect ( De Soto, 1967 ) ,[object Object],[object Object],© 2002 EPL-Institute
Individuals and RM – problems with causality. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Groups and RM ,[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Groups and RM - groupthink ,[object Object],[object Object],© 2002 EPL-Institute
Organisations and RM ,[object Object],[object Object],[object Object],© 2002 EPL-Institute
Organisational responses to hazards  (Westrum 1988) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Part 4 – Human Error © 2002 EPL-Institute
Human Error ,[object Object],[object Object],[object Object],© 2002 EPL-Institute
Human Error definition ,[object Object],[object Object],© 2002 EPL-Institute
Data from Telecom sector ,[object Object],[object Object],© 2002 EPL-Institute
Data from experiments and real life shows ,[object Object],[object Object],[object Object],© 2002 EPL-Institute
Theory of Human Error ,[object Object],[object Object],© 2002 EPL-Institute
Origin of Errors according to GEMS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
GEMS and Errors ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Contributing Factors ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
GEMS cognitive Model ,[object Object],© 2002 EPL-Institute
GEMS- Generic Error Modelling System © 2002 EPL-Institute
Error Frequences ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Error detection and frequences ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Minimizing Human Error ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Techniques for Human Error Identification ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Error Summary ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Part 5 – Risk Management Tools © 2002 EPL-Institute
Which tools for what ,[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Some TYPES of analysis ,[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Preliminary Hazard Analysis (PHA) ,[object Object],[object Object],[object Object],© 2002 EPL-Institute
Subsystem Hazard Analysis (SSHA) ,[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
System Hazard Analysis (SHA) ,[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Operating & Support Hazard Analysis (O&SHA) ,[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute
Some TECHNIQUES  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],© 2002 EPL-Institute

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Risk management seminar -en

  • 1. Risk Management & Human Error “ For a successful technology, reality must take precedence over public relations, for nature cannot be fooled. ” – Richard P. Feynman Report of the Presidential Commission on the Space Shuttle Challenger Accident © 2002 EPL-Institute
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  • 3. Part1 , Introduction to Risk Management © 2002 EPL-Institute
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  • 7. Risk Concepts part2 © 2002 EPL-Institute
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  • 17. Part 2 , components and processes © 2002 EPL-Institute
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  • 19. Components of Risk Management © 2002 EPL-Institute Risk Management consists of several components: Process Control Hazard Analysis Risk Assessment Risk Mitigation Fault Collection
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  • 23. Steps in Hazard Analysis © 2002 EPL-Institute
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  • 42. Example of Risk Management Process © 2002 EPL-Institute Risk Mitigation Risk Analysis Process Control / Fault Collection Develop Controls & Make Risk Decision Assess Hazards Supervise & Evaluate Identify Hazards Implement Controls
  • 43. © 2002 EPL-Institute The objective is to identify hazards that may cause accidents. Step 1: Identify Hazards Develop Controls & Make Risk Decision Identify Hazards Assess Hazards Supervise & Evaluate Implement Controls
  • 44. © 2002 EPL-Institute Assess hazards to determine risks. Assess the impact of each hazard in terms of potential for loss, based on probability and severity Develop Controls & Make Risk Decision Identify Hazards Assess Hazards Supervise & Evaluate Step 2: Assess Hazards Implement Controls Identify Hazards
  • 45. © 2002 EPL-Institute Develop control measures that eliminate the hazard or reduce its risk to an acceptable level Implement Controls Develop Controls & Make Risk Decision Assess Hazards Supervise & Evaluate Step 3: Develop Controls & Make Decision Identify Hazards
  • 46. © 2002 EPL-Institute Take action to put the controls in place that eliminate the hazards or reduce their risks Step 4: Implement Controls Implement Controls Develop Controls & Make Risk Decision Assess Hazards Supervise & Evaluate Identify Hazards
  • 47. © 2002 EPL-Institute Perform to, and enforce standards and controls. Evaluate the effectiveness of controls and adjust/ update as necessary Develop Controls & Make Risk Decision Assess Hazards Supervise & Evaluate Step 5: Supervise & Evaluate Identify Hazards Implement Controls
  • 48. Part 3 – Traps and common mistakes in Risk Management © 2002 EPL-Institute
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  • 68. Part 4 – Human Error © 2002 EPL-Institute
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  • 78. GEMS- Generic Error Modelling System © 2002 EPL-Institute
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  • 84. Part 5 – Risk Management Tools © 2002 EPL-Institute
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Notas do Editor

  1. Data from http://www.hcra.harvard.edu/ Statistics collcted by CDC
  2. NOTE TO PRESENTER : In this slide and in every slide showing a basic RM step, a brief explanation of that step will be displayed to the right. This is the first step, Identify hazards . In this step units should be considering everything that could reasonably go wrong doing an operation. That is reasonably everything conceivable.
  3. This step is more of art than a science. No matter how units assess risks, it must be based on probability and severity.
  4. The Basic objective of this step is to either eliminate the hazard entirely or to reduce the risk to an acceptable level. This is a very busy step. In this step we develop and select controls for each hazard, determine the residual risk of each hazard, determine an overall mission risk, and finally make a decision.
  5. The fourth step of the risk management process is to put the controls in place that eliminate the hazards or reduce their risk to a level we are willing to accept..
  6. The last step of the Risk Management Process is to Supervise and Evaluate. This is to perform to, and enforce the standard. Remember, you are accountable for your actions - so be responsible. Every soldier is responsible for performing to standard and executing controls. Every soldier is responsible for recognizing unsafe acts or conditions and, depending on the situation and time requirements, making on-the-spot corrections and/or bringing it to the attention of the chain of command. Leaders and supervisors are also responsible for ensuring standards and controls are followed and enforced.
  7. From Swedrups System Safety Scrapbook