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Shifting the Cultural Paradigm for the Prevention of Catastrophic and Fatal Events

机译：转变文化范式，预防灾难性和致命事件

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摘要

The relative infrequency of fatalities and other serious events can give them an appearance of being random, of being beyond any reasonable degree of anticipation and prevention. In fact, the vast majority of these events result from exposures that are identifiable, measurable, and manageable. The lessons of prominent incidents, such as the Space Shuttle Columbia, Oxy's Piper Alpha, Esso Longford, BP Texas City, Massey Mine, as well as lessons from single fatality events, is that alongside the proximate causes of each incident, there also coexisted an underlying fabric of systems, mechanisms, and culture that allowed risk in the workplace to persist and often to become normalised. All of these ingredients of the organisation's safety fabric lend themselves to the influence and intervention of senior leaders. The difficulty is that traditional injury prevention paradigms are not sufficient for addressing the precursors that lead up to catastrophic and fatal events. A recent study of such events, led by Dr Thomas Krause concluded that the descriptive aspect of Heinrich's safety triangle is useful, but that the predictive aspect is not. The study surfaced reasons why a reduction in less serious injuries does not necessarily correspond to a proportionate reduction in catastrophic and fatal risks. This presentation expands on the findings to include the concept of exposure to the event potential linked to precursor events and the framework for leading an organisation to be both cognisant and effective in eliminating such events.
机译：死亡和其他严重事件的相对频率不高会使他们看起来是随机的，超出了任何合理的预期和预防范围。实际上，这些事件中的绝大多数是由可识别，可测量和可管理的暴露引起的。重大事件的教训，例如哥伦比亚航天飞机，奥克斯派珀阿尔法，埃索·朗福德，英国得克萨斯州BP市，梅西矿山等的重大事故的教训，以及每次死亡事件的教训，都与每个事故的直接原因并存。系统，机制和文化的基本结构，使工作场所的风险持续存在并且经常被规范化。该组织安全架构的所有这些要素都有助于高层领导的影响和干预。困难在于传统的伤害预防范式不足以解决导致灾难性和致命事件的先兆。由Thomas Krause博士领导的对此类事件的最新研究得出结论，Heinrich安全三角的描述性方面很有用，但预测性却无济于事。该研究浮出水面的原因是，减少轻度伤害并不一定相应地减少灾难性和致命性风险。本演示文稿将对发现进行扩展，包括暴露于与前兆事件相关的事件潜在风险的概念，以及使组织在消除此类事件方面具有认知力和有效性的框架。

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  • 会议地点 Melbourne(AU)
  • 作者

    R Russell;

  • 作者单位

    Russell Consulting International (on behalf of BST™), 177b Dorcas Street, South Melbourne Vic 3205;

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  • 正文语种 eng
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