General Safety Flashcards
The balance between production and protection is known as the _________ zone. Too much protection leads to __________, while excessive production emphasis leads to ___________.
parity / bankruptcy / catastrophe
Note: Catastrophe will likely come after a gradual fluctuation of declines within the parity zone. Fluctuations will be caused by reactionary protections from less severe accidents or even near misses.
Regarding safety in a technological org., what are the two competing goals?
Production vs Protection
Define risk homeostasis or compensation
An added protection will gradually lead to increased production, thus reducing the protections effectiveness.
Eg: Ship radar led to increased speed in foggy conditions.
Without negative events and conscious efforts regarding protection, name two other factors that will reduce an org’s position in the parity range?
Time
Productive Growth
In modern technologies such as the aviation and nuclear industries, there are very few ____________ accidents. The greatest danger comes from rare, but often disastrous, ____________ accidents.
individual
organization
T or F?
Reason’s “Swiss Cheese Model” of hazard defenses is constantly in flux, with defensive holes changing alignment, or various layers potentially even disappearing completely.
True
What is considered an “active” failure?
An active failure is the direct or immediate cause of an undesirable event at the human - system interface.
What is constitutes an “latent” failure?
A latent failure is the underlying condition(s) that contribute to an active failure
Name two common characteristics of latent failures?
- Origin in upper echelons of an organization.
2. Can lie dormant for long periods until the right set of circumstances align to allow an adverse event
T or F
Latent conditions, if undiscovered and uncorrected, can lead to an increase in active failures and accidents.
True
In the Model of Accident Causality, the system that produces an accident is made up of what three elements?
- Unsafe Acts
- Local Workplace Factors
- Organizational Factors
Note: Accident causality flows from 1 to 3, while investigations are opposite from 3 to 1. Further, investigations must be confined to the manageable boundaries of the org concerned.
Regarding accident causation, in what elements can latent conditions play a factor?
Org Factors
Local Workplace Factors
Human tendencies, along with what element in the accident causation model, tend to produce a large amount of unsafe acts, with very few actually creating holes in defenses?
Local Workplace Factors
Although unsafe acts are implicated in most org accidents, are they a necessary condition?
No - think “Challenger”
What is the most common maintenance lapse in both the aviation and nuclear power industries?
Reassembly omissions
T or F
Latent conditions are always present in complex systems.
True; even now!
T or F
Production and protection processes are part of the same organizational structure.
True
Latent conditions are an ____________ product of strategic decisions. All safety can do, is make the worst __________ at any one time, so they can be corrected.
inevitable / visible
It is said that Risk Mgmt is one damn thing after another.
What is one common reason why latent or defensive weaknesses are not detected and repaired?
Those involved have forgotten to be afraid. Safety is a dynamic, non-event.
Production and profit goals are immediate and constant, whereas bad outcomes are very rare in well defended systems.
A common question after an accident is, “How could the warning signs have been missed?” This is asked by those who are using 20/20 hindsight or _________ _________ vs the limited foresight of accident participants.
outcome knowledge
Several studies have shown that outcome knowledge biases our judgment of accident participants because of what three reasons?
- Overestimation of what they would have known in foresight
- Overestimation of what others knew in foresight
- They misremember what they themselves knew in foresight.
Note: A prior Indication of an accident is only a warning if you know what kind of disaster you will suffer.
Automation mode confusion happens f one of two broad reasons?
- Wrong assessment of active mode
2. Failure to notice a change in mode status