Managing Risk - The Human Element

Contents About the Authors Preface Acknowledgements Defi nitions of Risk and Risk Management Introduction: The Art of Prediction and the Creation of Order Risk and Risk Management Defi ning Risk Managing Risk: Our Purpose, Plan and Goals Recent Tragic Outcomes Power Blackouts, Space Shuttle Losses, Concorde Crashes, Chernobyl, Three Mile Island and More ... How Events and Disasters Evolve in a Phased Development: The Human Element Our Values at Risk: The Probable Improvement Probably or Improbably Not How this Book is Organised References Technical Summary Defi ning the Past Probability Predicting Future Risk: Sampling from the Jar of Life A Possible Future: Defi ning the Posterior Probability The Engineers Have an Answer: Reliability Drawing from the Jar of Life: The Hazard Function and Species Extinction Experiencing Failure: Engineering and Human Risk and Reliability Experience Space Managing Safely: Creating Order out of Disorder Using Safety Management Systems Describing the Indescribable: Top-Down and Bottom-Up What an Observer will Observe and the Depth of our Experience References 1 The Universal Learning Curve Predicting Tragedies, Accidents and Failures: Using the Learning Hypothesis The Learning Hypothesis: The Market Place of Life Learning in HTSs: The Way a Human Learns Evidence of Risk Reduction by Learning Evidence of Learning from Experience: Case Studies Evidence of Learning in Economics Evidence of Learning in Engineering and Architecture: The Costs of Mistakes Learning in Technology: the Economics of Reducing Costs Evidence of Learning Skill and Risk Reduction in the Medical Profession: Practice Makes Almost Perfect Learning in HTSs: The Recent Data Still Agrees The Equations That Describe the Learning Curve Zero Defects and Reality Predicting Failures: The Human Bathtub Experience Space: The Statistics of Managing Safety and of Observing Accidents Predicting the Future Based on Past Experience: The Prior Ignorance Future Events: the Way Forward Using Learning Probabilities The Wisdom of Experience and Inevitability The Last, First or Rare Event Conclusions and Observations: Predicting Accidents References 2 The Four Echoes Power Blackouts, Space Shuttle Losses, Concorde Crashes, and the Chernobyl and Three Mile Island Accidents The Combination of Events The Problem Is the Human Element The Four Echoes Share the Same Four Phases The First Echo: Blackout of the Power Grid Management's Role The First Echo: Findings Error State Elimination The Second Echo: Columbia/Challenger The Results of the Inquiry: Prior Knowledge The Second Echo: The Four Phases Management's Responsibility Error State Elimination The Third Echo: Concorde Tires and SUVs Tire Failures: the Prior Knowledge The Third Echo: The Four Phases Management's Responsibility Error State Elimination The Fourth Echo: Chernobyl The Chernobyl Accident: An Echo of Three Mile Island The Consequences Echoes of Three Mile Island The Causes Error State Elimination The Fourth Echo: The Four Phases Regulatory Environment and Practices Case study: Regulation in Commercial Aviation a) Regulations Development b) Compliance Standards c) Accident Investigation Addressing Human Error Management Responsibilities Designing to Reduce Risk and the Role of Standards Conclusion and Echoes: Predicting the Unpredictable References 3 Predicting Rocket Risks and Refi nery Explosions: Near Misses, Shuttles, Safety and Anti-Missile Defence Systems Effectiveness Learning from Near Misses and Prior Knowledge Problems in Quantifying Risk: Predicting the Risk for the Next Shuttle Mission Estimating a Possible Range of Likelihoods Learning from Experience: Maturity Models for Future Space Mission Risk Technology versus Technology Missiles Risks over London: The German Doodlebug Launching Missile Risk The Number of Tests Required Estimating the Risk of a Successful Attack and How Many Missiles We Must Fire Uncertainty in the Risk of Failing to Intercept What Risk Is There of a Missile Getting Through: Missing the Missile Predicting the Risk of Industrial Accidents: The Texas City Refinery Explosion From Lagging to Leading: Safety Analysis and Safety Culture Missing Near Misses What these Risk Estimates Tell Us: The Common Sense Echo References 4 The Probability of Human Error: Learning in Technological Systems What We Must Predict The Probability Linked to the Rate of Errors The Defi nition of Risk Exposure and the Level of Attainable Perfection Comparison to Conventional Social Science and Engineering Failure and Outcome Rate Formulations The Learning Probabilities and the PDFs The Initial Failure Rate and its Variation with Experience The 'Best' MERE Risk Values Maximum and Minimum Likely Outcome Rates Standard Engineering Reliability Models Compared to the MERE Result Future Event Estimates: The Past Predicts the Future Statistical Bayesian-Type Estimates: The Impact of Learning Maximum and Minimum Likelihood Comparison to Data: The Probability of Failure and Human Error Comparison of the MERE Result to Human Reliability Analysis Implications for Generalised Risk Prediction Conclusions: The Probable Human Risk References 5 Eliminating Mistakes: The Concept of Error States A General Accident Theory: Error States and Safety Management The Physics of Errors The Learning Hypothesis and the General Accident Theory Observing Outcomes A Homage to Boltzmann: Information from the Grave The Concept of Depth of Experience and the Theory of Error States The Fundamental Postulates of Error State Theory The Information in Error States: Establishing the Risk Distribution The Exponential Distribution of Outcomes, Risk and Error States The Total Number of Outcomes The Observed Rate and the Minimum Number of Outcomes Accumulated Experience Measures and Learning Rates The Average Rate Analogy and Predictions: Statistical Error Theory and Learning Model Equivalence The Infl uence of Safety Management and Regulations: Imposing Order on Disorder The Risk of Losing a Ship Distribution Functions The Most Probable and Minimum Error Rate Learning Rates and Experience Intervals: The Universal Learning Curve Reducing the Risk of a Fatal Aircraft Accident: the Infl uence of Skill and Experience Conclusions: A New Approach References 6 Risk Assessment: Dynamic Events and Financial Risks Future Loss Rate Prediction: Ships and Tsunamis Predicted Insurance Rates for Shipping Losses: Historical Losses The Premium Equations Financial Risk: Dynamic Loss and Premium Investments Numerical Example Overall Estimates of Shipping Loss Fraction and Insurance Inspections The Loss Ratio: Deriving the Industrial Damage Curves Making Investment Decisions: Information Drawing from the Jar of Life Information Entropy and Minimum Risk Progress and Learning in Manufacturing Innovation in Technology for the Least Product Price and Cost: Reductions During Technological Learning Cost Reduction in Manufacturing and Production: Empirical Elasticity 'Power Laws' and Learning Rates A New General Formulation for Unit Cost Reduction in Competitive Markets: the Minimum Cost According to a Black-Scholes Formulation Universal Learning Curve: Comparison to the Usual Economic Power Laws The Learning Rate b-Value 'Elasticity' Exponent Evaluated Equivalent Average Total Cost b-Value Elasticity Profi t Optimisation to Exceed Development Cost The Data Validate the Learning Theory a) Aircraft Manufacturing Costs Estimate Case b) Photovoltaic Case c) Air Conditioners Case d) Ethanol Prices Case e) Windpower Case f) Gas Turbine Power Case g) The Progress Curve for Manufacturing Non-Dimensional UPC and Market Share Conclusions: Learning to Improve and Turning Risks into Profits References 7 Safety and Risk Management Systems: the Fifth Echoes Safety Management Systems: Creating Order Out of Disorder Workplace Safety: The Four Rights, Four Wrongs and Four Musts Acceptable Risk: Designing for Failure and Managing for Success Managing and Risk Matrices Organisational Factors and Learning A Practical 'Safety Culture' Example: The Fifth Echo Safety Culture and Safety Surveys: The Learning Paradox Never Happening Again: Perfect Learning Half a World Apart: Copying the Same Factors Using a Bucket: Errors in Mixing at the JCO Plant Using a Bucket: Errors in Mixing at the Kean Canyon Explosives Plant The Prediction and Management of Major Hazards: Learning from SMS Failures Learning Environments and Safety Cultures: The Desiderata of Desires Safety Performance Measures: Indicators and Balanced Scorecards Safety and Performance Indicators: Measuring the Good Human Error Rates Passing Red Lights, Runway Incursions and Near Misses Risk Informed Regulation and Degrees of Goodness: How Green is Green? Modelling and Predicting Event Rates and Learning Curves Using Accumulated Experience Using the Past to Predict the Future: How Good is Good? Reportable Events Scrams and Unplanned Shutdowns Common Cause Events and Latent Errors Performance Improvement: Case-by-Case Lack of Risk Reduction: Medical Adverse Events and Deaths New Data: Sentinel Events, Deaths and Blood Work Medication Errors in Health Care Organisational Learning and Safety Culture: the 'H-Factor' Risk Indicator Data Analysis: A Case Study Meeting the Need to Measure Safety Culture: the Hard and the Soft Elements Creating Order from Disorder References 8 Risk Perception: Searching for the Truth Among all the Numbers Perceptions and Predicting the Future: Risk Acceptance and Risk Avoidance Fear of the Unknown: The Success Journey into What We Do or Do Not Accept A Possible Explanation of Risk Perception: Comparisons of Road and Rail Transport How Do We Judge the Risk? Linking Complexity, Order, Information Entropy and Human Actions Response Times, Learning Data and the Universal Laws of Practice The Number and Distribution of Outcomes: Comparison to Data Risk Perception: Railways Risk Perception: Coal Mining Risk Perception: Nuclear Power in Japan Risk Perception: Rare Events and Risk Rankings Predicting the Future Number of Outcomes A Worked Example: Searching out and Analysing Data for Oil Spills Typical Worksheet Plotting the Data Fitting a Learning Curve Challenging Zero Defects Comparison of Oil Spills to other Industries Predicting the Future: the Probability and Number of Spills Observations on this Oil Spill Case Knowing What We Do Not Know: Fear and Managing the Risk of the Unknown White and Black Paradoxes: Known Knowns and Unknown Unknowns The Probability of the Unknowns: Learning from What We Know The Existence of the Unknown: Failures in High Reliability Systems The Power of Experience: Facing Down the Fear of the Unknown Terrorism, Disasters and Pandemics: Real, Acceptable and Imaginary Risks Estimating Personal Risk of Death: Pandemics and Infectious Diseases Sabotage: Vulnerabilities, Critical Systems and the Reliability of Security Systems What Is the Risk? The Four Quadrants: Implications of Risk for Safety Management Systems References 9 I Must Be Learning Where We Have Come From What We Have Learned What We Have Shown Legal, Professional and Corporate Implications for the Individual Just Give Me the Facts Where We Are Going Reference Nomenclature Appendices: Appendix A: The 'Human Bathtub': Predicting the Future Risk The Differential Formulation for the Number of Outcomes The Future Probability Insuffi cient Learning Appendix B: The Most Risk, or Maximum Likelihood, for the Outcome (Failure or Error) Rate while Learning The Most or Least Likely Outcome Rate The Maximum and Minimum Risk: The Two Solutions Low Rates and Rare Events The Limits of Maximum and Minimum Risk: The Two Solutions Common Sense: The Most Risk at the Least Experience and the Least Risk as the First Outcome Decreases with Experience Typical Trends in Our Most Likely Risk The Distribution with Depth of Experience References Appendix C: Transcripts of the Four Echoes Power Blackout, Columbia Space Shuttle loss, Concorde Crash and Chernobyl Accident The Combination of Events The Four Echoes Share the Same Four Phases Appendix. Blackout Chronology and the Dialog from Midday 14 August 2003 The Second Echo: Columbia/Challenger Appendix: Shuttle Dialog and Transcripts The Third Echo: Concorde Tires and SUVs Appendix: Dialog for the Concorde Crash The Fourth Echo: TMI/Chernobyl Appendix: Chronology and Transcripts of the Chernobyl Reactor Unit 4 Accident Conclusion and Echoes: Predicting the Unpredictable Appendix D: The Four Phases: Fuel Leak Leading to Gliding a Jet in to Land without any Engine Power The Bare Facts and the Sequence The Four Phases Flight Crew Actions Initial Recognition of the Fuel Loss Crew Reaction to the Fuel Imbalance Advisory (05:33-05:45) Crew Reaction to the Continued Fuel Loss (05:45-06:10) Crew Reaction to the (Two) Engine Failures References Appendix E: The Four Phases of a Midair Collision The Bare Facts The Four Phases References Appendix F: Risk From the Number of Outcomes We Observe: How Many Are There? The Number of Outcomes: The Hypergeometric Distribution Few Outcomes and many Non-Outcomes: The Binomial and Poisson Distributions The Number of Outcomes: In the Limit The Perfect Learning Limit: Learning from Non-Outcomes The Relative Change in Risk When Operating Multiple Sites References Appendix G: Mixing in a Tank: The D.D. Williamson Vessel Explosion Errors in Mixing in a Tank at the Caramel Factory: The Facts The Prior Knowledge Another Echo References Appendix H: Never Happening Again The Risk of an Echo, or of a Repeat Event The Matching Probability for an Echo The Impact of Learning and Experience on Managing the Risk of Repeat Events The Theory of Evidence: Belief and Risk Equivalence References Appendix I: A Heuristic Organisational Risk Stability Criterion Order and Disorder in Physical and Management Systems Stability Criterion References Appendix J: New Laws of Practice for Learning and Error Correction Individual Learning and Practice Comparison to Error Reduction Data Comparison to Response Time Data and the Consistent Law of Practice Reconciling the Laws Conclusions References Appendix K: Predicting Rocket Launch Reliability - Case Study Summary Theory of Rocket Reliability a) Unknown Total Number of Launches and Failures b) Known Total Number of Launches and Failures Results Measures of Experience Comparsion to World Data Predicting the Probability of Failure Statistical Estimates of the Failure Probability for the Very 'next' launch Independent Validation of the MERE Launch Failure Curve Observations References Illustrations Pipeline Spill and Fire Train Crash Due to SPAD Space Shuttle Columbia Chemical Explosion Bayes, Laplace and Bernouli Kean Canyon Explosion Boltzmann's Grave Quebec Overpass Index