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Store og små ulykker

Store og små ulykker. Indikatorer for styring av sikkerhet. Luftfart og Deepwater Horizon. Storulykkesrisiko. Arbeidsulykkesrisiko. Hovedkarakteristika: Multi-lineær hendelseskjede Kompleks årsakssammenheng Potensielle katastrofale konsekvenser Potensial for spredning/eskalering.

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Store og små ulykker

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  1. Store og små ulykker Indikatorer for styring av sikkerhet

  2. Luftfart og Deepwater Horizon

  3. Storulykkesrisiko Arbeidsulykkesrisiko • Hovedkarakteristika: • Multi-lineær hendelseskjede • Kompleks årsakssammenheng • Potensielle katastrofale konsekvenser • Potensial for spredning/eskalering • Hovedkarakteristika : • Lineær hendelseskjede • Enklere årsakssammenheng • Vanligvis begrensede konsekvenser

  4. Tenkning om storulykkerisiko i luftfart

  5. Et systemperspektiv for sikkerhetsarbeidet

  6. The Reason Model: The Organisational Accident Organisational factors Task/Environmental Conditions Individual/ Team Actions Defence Barriers Management Decisions and Organisational processes Error producing conditions Violation producing conditions Errors Violations Accident or major Incident

  7. Paradoks

  8. Arbeidsulykkerisiko i luftfart Total Recordable Injuries (TRI) And Lost Workday Cases (LWC) Per 100 Employees* 14 12 10.5 10.0 10 8.2 8 All Industry Averages LWC 1.4 TRI 4.8 6.4 6 5.5 4.8 . 4.0 4 3.5 3.5 3.2 2.4 2.7 2.5 1.9 2 0.9 0.9 1.0 1.0 0.8 1.13 1.0 0.25 0 DuPont (2005) Chemicals Elec. Pwr. Gen. Construction Textile Mills Aerospace Mfg Wood Products Pulp & Paper Mfg Oil & Gas Pipelines Food Manufacturing Sched. Commercial Air * U.S. Bureau of Labor Statistics, 2004 Data

  9. Arbeidsulykkerisiko i luftfart Recordable Injuries/Illnesses US Fatalities 2003 7 2004 14 2005 3 Ramp Freight Flight Crew Line Maintenance Customer Service Heavy Maintenance Ground Svcs Equip. Flight Attendants

  10. Bakkehendelser • 27000 ulykker og hendelser på ramp hvert år • 243000 personskader hvert år – omlag 9 pr 1000 avganger “IATA attributes the problem to "minimal oversight" of ground service providers in the selection and licensing process, in systems implementation, training and development, and in auditing, reporting and compliance procedures”

  11. Kostnader • Flight Safety Foundation: Dobbelt så høyere kostnader som antatt – nær 10 milliarder dollar hvert år “The reason, says the FSF’s Ground Accident Prevention (GAP) programme analyst, Dr Earl Weener, is that personal injury costs had been “right off the radar” for the airlines, but have now been estimated for the first time at $4.4 billion in addition to the $5 billion cost of aircraft damage repair, downtime and delay”

  12. Luftfart og Deepwater Horizon

  13. Styring av sikkerhet Safetyis the state in which the risk of harm to persons or property damage is reduced to, and maintained at or below, an acceptable level through a continuing process of hazard identification and risk management(ICAO, DOC 9859)

  14. Etabler indikatorer • For individulykker • For storulykker

  15. Leading indicators: Active monitoring: provides feedback on performance before an accident or incident Check that key actions or activities are undertaken as intended Lagging indicators: Reactive monitoring: reporting and investigation of specific incidents Show when a desired safety outcome has failed, or has not been achieved Leading indicators / lagging indicators Hentet fra Developing process safety indicators. Tilgjengeiig fra: www.hse.gov.uk/pubns/books/hsg254.htm www.perceptualedge.com

  16. Oppfølging av sykefravær / skader / h-verdi Revisjoner Risikoanalyser Analyse av driftsdata Observasjoner av normal drift FDM / FOQA LOSA / NOSS Vedlikeholdsdata Hendelsesregistrering Antall hendelser; flyoperativt, ground, maintenance Hendelsesgranskning Sikkerhetskulturkartlegging Arbeidsmiljøkartlegginger Typiske indikatorer

  17. Bakkeskader og flight safety Monday 26/12 2005 Alaska Airlines Flight 536 was 20 minutes out of Seattle and heading for Burbank, Calif., Monday afternoon when a thunderous blast rocked the plane. An investigator with the National Transportation Safety Board (NTSB) said baggage handlers had bumped the plane's fuselage with loading equipment and caused "a crease" in the side of the aircraft

  18. Finn de riktige tiltakene The wrong mitigating actions can potentially make things worse Do you want the green pill or the red pill?

  19. Safeguarding life, property and the environment www.dnv.com

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