In their work as health care professionals, both authors have gained vital experience in error ma... more In their work as health care professionals, both authors have gained vital experience in error management. They draw our attention to the human tendency to focus only on a single reason when dealing with errors. To mitigate this tendency, they show a two-step alternative process. The first step, a “sequence of events analysis,” is conducted immediately after an accident or near miss. This data capture serves to inform the later, second analysis, called a “focused event analysis.” The focused event analysis is a causal analysis study involving all key stakeholders for the purpose of seeking knowledge about the contributing variables and the steps that can be taken to eliminate system vulnerabilities.
International Conference on Multimedia Information Networking and Security, 2007
ABSTRACT http://www.annales.org/re/2007/re45-janvier-07.html La catastrophe d’AZF marquera durabl... more ABSTRACT http://www.annales.org/re/2007/re45-janvier-07.html La catastrophe d’AZF marquera durablement les esprits. Pour les Toulousains c’est un traumatisme. Mais elle a aussi, et même si la recherche des causes n’a pas encore dissipé toutes les zones d’ombre, avec la loi qui a suivi, permis d’avancer vers un développement durable de l’industrie et des zones urbaines. Elle a même permis à la France de précéder ses partenaires européens sur la voie que, constatant avec Enschede et Toulouse les limites de la directive Seveso, préconise désormais le Parlement européen. Passer face à « l’impossible risque zéro » à une logique « d’éloignement du risque ». Description et bilan des conséquences de la catastrophe au travers des rapports de l’Ineris.
ABSTRACT Organisational diagnosis enables to complete human factors diagnosis devoted to sensitiv... more ABSTRACT Organisational diagnosis enables to complete human factors diagnosis devoted to sensitive activities analysis. It is frequent to hear (e.g., Reason, 1990, Vaughan, 1996) that the two configurations to conduct the diagnosis (before or after the event) would not be comparable in terms of investigation modalities and judgment performance. Some signals could only be understood in hindsight (e.g., in Challenger, Vaughan, 1996). Lessons of accidents (e.g., Texas City) and the practical experience enable to settle a discussion on organisational diagnosis key variables: role of incidents, actors’ speech, reception of results, conduct of investigation and judgment performance. After analysis, there is no strict dichotomy in the conduct of investigations and the findings to expect. This discussion has some theoretical consequences (normal accident theories, A-typical accidents, accidents “royal road” and culture of accidents).
In their work as health care professionals, both authors have gained vital experience in error ma... more In their work as health care professionals, both authors have gained vital experience in error management. They draw our attention to the human tendency to focus only on a single reason when dealing with errors. To mitigate this tendency, they show a two-step alternative process. The first step, a “sequence of events analysis,” is conducted immediately after an accident or near miss. This data capture serves to inform the later, second analysis, called a “focused event analysis.” The focused event analysis is a causal analysis study involving all key stakeholders for the purpose of seeking knowledge about the contributing variables and the steps that can be taken to eliminate system vulnerabilities.
International Conference on Multimedia Information Networking and Security, 2007
ABSTRACT http://www.annales.org/re/2007/re45-janvier-07.html La catastrophe d’AZF marquera durabl... more ABSTRACT http://www.annales.org/re/2007/re45-janvier-07.html La catastrophe d’AZF marquera durablement les esprits. Pour les Toulousains c’est un traumatisme. Mais elle a aussi, et même si la recherche des causes n’a pas encore dissipé toutes les zones d’ombre, avec la loi qui a suivi, permis d’avancer vers un développement durable de l’industrie et des zones urbaines. Elle a même permis à la France de précéder ses partenaires européens sur la voie que, constatant avec Enschede et Toulouse les limites de la directive Seveso, préconise désormais le Parlement européen. Passer face à « l’impossible risque zéro » à une logique « d’éloignement du risque ». Description et bilan des conséquences de la catastrophe au travers des rapports de l’Ineris.
ABSTRACT Organisational diagnosis enables to complete human factors diagnosis devoted to sensitiv... more ABSTRACT Organisational diagnosis enables to complete human factors diagnosis devoted to sensitive activities analysis. It is frequent to hear (e.g., Reason, 1990, Vaughan, 1996) that the two configurations to conduct the diagnosis (before or after the event) would not be comparable in terms of investigation modalities and judgment performance. Some signals could only be understood in hindsight (e.g., in Challenger, Vaughan, 1996). Lessons of accidents (e.g., Texas City) and the practical experience enable to settle a discussion on organisational diagnosis key variables: role of incidents, actors’ speech, reception of results, conduct of investigation and judgment performance. After analysis, there is no strict dichotomy in the conduct of investigations and the findings to expect. This discussion has some theoretical consequences (normal accident theories, A-typical accidents, accidents “royal road” and culture of accidents).
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