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The communication system
The failure of management responsibility
Was Moura safetyconscious?
Production before safety?
The role of BHP
The safety pays argument
The regulatory system
Company and management hierarchies
Other editions - View all
accidents action alarm analysis argument Australia Bass Strait behaviour belief benzene Bhopal BHPAC catastrophic risk chapter coal mines concern context control of catastrophic corporate cost crew culture of denial danger deputies develop disaster prevention duty of care effective EFTPOS employers ensure evidence explosive range failed gas monitoring go underground happened head office health and safety heating hierarchy identify ignition indicator industry inspec inspectorates involved Kianga lessons litres per minute lost time injury LTIFR matter mine's Moura disaster normal accidents North Sea noted occurring oil platform oral communication organisation panel particular Perrow perspectives Piper Alpha possible potential practice prescriptive priority problem procedures production Queensland question rational reports of smells responsibility for safety safe safety management plans safety pays sealed self-regulation senior management shift undermanager specified spontaneous combustion system accidents tion trigger underground that night undermanager-in-charge Union Carbide warning signs Windridge workers
Page 46 - Once formed, initial impressions tend to structure the way that subsequent evidence is interpreted. New evidence appears reliable and informative if it is consistent with one's initial belief; contrary evidence is dismissed as unreliable, erroneous, or unrepresentative.
Page 114 - Rather than attempting a comprehensive survey and evaluation of all alternatives, the decision-maker focuses only on those policies which differ incrementally from existing policies. 2. Only a relatively small number of policy alternatives are considered. 3. For each policy alternative, only a restricted number of "important
Page 18 - Their defining feature is that they were present within the system well before the onset of a recognisable accident sequence. They are most likely to be spawned by those whose activities are removed in both time and space from the direct humanmachine interface: designers, high-level decision makers, regulators, managers and maintenance staff. Reasons argues that an accident or near miss of the type discussed above is usually an 'organisational
Page 113 - Do they need an indicator to tell them whether the deck storekeeper is awake and sober? My goodness!
Page 137 - That is, a situation in which latent failures, arising mainly in the managerial and organisational spheres, combine adversely with local triggering events (weather, location etc) and with the active failures of individuals at the sharp end (errors and procedural violations).
Page 116 - Clearly, by any objective measure, UCC [Union Carbide Corporation] and its managers benefited from the Bhopal incident, as did UCIL [Union Carbide India, Ltd.]. They were politically able to close a burdensome plant, take aggressive actions to restructure both companies, and enhance management benefits. ... It is ironic that a disaster such as Bhopal would leave its victims devastated and other corporate stakeholders better off" (quoted in Lepkowski 1994, 30).
Page 18 - Latent failures: these are decisions or actions, the damaging consequences of which may lie dormant for a long time, only becoming evident when they combine with local triggering factors (that is, active failures, technical faults, atypical system conditions, etc) to breach the system's defences. Their defining feature is that they were present within the system well before the onset of a recognisable accident sequence.
Page 49 - ... the onus is on the prosecution to prove beyond reasonable doubt that the...
Page 89 - ... severity risks are being carefully controlled. On the contrary, the danger is that a single-minded focus on reducing the LTIFR leads systematically to the neglect of catastrophic risk. Where there is potential for catastrophe, safety management must not be driven exclusively by a concern to reduce the lost time injury frequency rate. That way lies disaster, quite literally.