linked indiscussion2014 tower

10
A new Mindset... The Risks and the Causes & Effects of Accidents or “The Filtering Tower”

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This model was developped by me in the same period of, a ndindependant from, Reason's Swiss Cheese Model Although it isa far more dynamic model, closer to reality it had never the success the SCM had. I am no professor and simply a SIBEENG (SIlly BElgian ENGineer).

TRANSCRIPT

Page 1: Linked indiscussion2014 tower

A new Mindset...

The Risks and the Causes & Effects of

Accidents or

“The Filtering Tower”

Page 2: Linked indiscussion2014 tower

Principle of Multiple Causes

”Problems and undesired events are seldom, if ever, the result of a single cause "

Risks and the Causes of Accidents

Page 3: Linked indiscussion2014 tower

Principle of sequence

" Problems and undesired events are caused by many causes, many of them linked in causal or temporal sequence"

Risks and the Causes of Accidents

Page 4: Linked indiscussion2014 tower

HAZARD VULNERABLE

OBJECT

B

A

R

R

I

E

R

• PEOPLE - Unsafe Behavior

• PROCESS

• LOCATION

• MACHINES / TOOLS

• AGENTS

ENERGY CONTROLS TO PROTECT

• PEOPLE - Safe Behavior

• MANAGEMENT SYSTEMS

• PROGRAMMES, PRACTICES &

PROCEDURES

• FACILITIES & TOOLS (Ergonomics)

• PEOPLE

• PROPERTY

• ENVIRONMENT

Near Miss

Accident

Incident Causation & Prevention Model (Bill Johnson - MORT)

Page 5: Linked indiscussion2014 tower

People are key, reason for our focus !

PEOPLE,

PROCESS,

LOCATION ETC.

ENERGY

TO PROTECT

PEOPLE

FACILITIES & EQUIPMENT

PRACTICES / PROCEDURES (HOW?)

MANAGEMENT SYSTEMS (WHAT?)

VULNERABLE

OBJECTS

HAZARD

PEOPLE

ARE KEY

Also emphasize “more energy=>severity

Page 6: Linked indiscussion2014 tower

Accepted Risks Not Identified Risks

Safety Management System (MOT)

©Loss Control Centre

Hazards

Page 7: Linked indiscussion2014 tower

Accepted Risks Not Identified Risks

Safety Management System (MOT)

Reality of the Workplace Behavior / Procedures / Conditions

Events

©Loss Control Centre

Hazards

Page 8: Linked indiscussion2014 tower

Accepted Risks Not Identified Risks

Safety Management System (MOT)

Reality of the Workplace Behavior / Procedures / Conditions

Events

Lo$$es

Treatment of the Events

©Loss Control Centre

Hazards

P

D

C

A

Page 9: Linked indiscussion2014 tower

Safety Management System

Reality of the Workplace

Treatment of the Events

©Loss Control Centre

Page 10: Linked indiscussion2014 tower

Safety Management System

Reality of the Workplace “Let’s by-pass the System”

Treatment of the Events

©Loss Control Centre