Jens Rolfsen ([email protected]) Store og små ulykker Indikatorer for styring av...

Jens Rolfsen ([email protected])

Store og små ulykker

Indikatorer for styring av sikkerhet

© Det Norske Veritas AS. All rights reserved.


Luftfart og Deepwater Horizon

2



3

Storulykkesrisiko Arbeidsulykkesrisiko

Hovedkarakteristika:

• Multi-lineær hendelseskjede

• Kompleks årsakssammenheng

• Potensielle katastrofale konsekvenser

• Potensial for spredning/eskalering

Hovedkarakteristika :

• Lineær hendelseskjede

• Enklere årsakssammenheng

• Vanligvis begrensede konsekvenser



4



5



6

Tenkning om storulykkerisiko i luftfart



7

Et systemperspektiv for sikkerhetsarbeidet

Man (M)

Technology (T) Organisation (O)

Man (M)

Technology (T) Organisation (O)



8

The Reason Model: The Organisational Accident

ManagementDecisions andOrganisational

processes

Errorproducingconditions

Violationproducingconditions

Errors

Violations

Organisational factors

Individual/ Team Actions

Task/Environmental Conditions

Defence Barriers

Accident or major Incident



9



10

Paradoks



10.510.0

8.2

0

2

4

6

8

10

12

14

DuPont

(2005)

Oil & Gas Pipelin

es

Elec. Pwr. G

en.

Chemicals

Pulp & Paper Mfg

Constructio

n

Aerospace Mfg

Textile Mills

Wood Products

Food Manufacturin

g

Sched. Commercial A

ir

Total Recordable Injuries (TRI)And Lost Workday Cases (LWC)

Per 100 Employees*

All Industry AveragesLWC 1.4 TRI 4.8

.5.5

2.71.9

6.4

2.43.5

0.9

3.5

0.9

3.2

1.0

2.5

1.01.130.25

* U.S. Bureau of Labor Statistics, 2004 Data

0.8

4.0

1.0

4.8

Arbeidsulykkerisiko i luftfart



Flight C

rewFreight

Heavy Maintenance

Line Maintenance

Customer Service

Ground Svcs Equip.

Flight A

ttendants

RampRamp

Recordable Injuries/Illnesses

US Fatalities2003 72004 142005 3

Arbeidsulykkerisiko i luftfart



Bakkehendelser

27000 ulykker og hendelser på ramp hvert år

243000 personskader hvert år – omlag 9 pr 1000 avganger

“IATA attributes the problem to "minimal oversight" of ground service providers in the selection and licensing process, in systems implementation, training and development, and in auditing, reporting and compliance procedures”

13



Kostnader

Flight Safety Foundation: Dobbelt så høyere kostnader som antatt – nær 10 milliarder dollar hvert år

14

“The reason, says the FSF’s Ground Accident Prevention (GAP) programme analyst, Dr Earl Weener, is that personal injury costs had been “right off the radar” for the airlines, but have now been estimated for the first time at $4.4 billion in addition to the $5 billion cost of aircraft damage repair, downtime and delay”



Luftfart og Deepwater Horizon

15



Styring av sikkerhet

16

SafetySafety is the state in which the risk of harm

to persons or property damage is reduced

to, and maintained at or below, an

acceptable levelacceptable level through a continuing

process of hazard identificationhazard identification and risk risk

management (ICAO, DOC 9859)management (ICAO, DOC 9859)



17

Etabler indikatorer

For individulykker

For storulykker

”Leadingindicators”

”Lagging indicators”

Måling avkonsekvens

Måling avstyring

”Leadingindicators”

”Lagging indicators”

Måling avkonsekvens

Måling avstyring



18

Leading indicators / lagging indicators Leading indicators:

- Active monitoring: provides feedback on performance before an accident or incident

- Check that key actions or activities are undertaken as intended

Lagging indicators:- Reactive monitoring: reporting and

investigation of specific incidents- Show when a desired safety

outcome has failed, or has not been achieved

Hentet fra Developing process safety indicators. Tilgjengeiig fra: www.hse.gov.uk/pubns/books/hsg254.htm

www.perceptualedge.com



19

Typiske indikatorer Oppfølging av sykefravær / skader / h-verdi

Revisjoner

Risikoanalyser

Analyse av driftsdata

Observasjoner av normal drift- FDM / FOQA- LOSA / NOSS

Vedlikeholdsdata

Hendelsesregistrering- Antall hendelser; flyoperativt, ground,

maintenance

Hendelsesgranskning

Sikkerhetskulturkartlegging

Arbeidsmiljøkartlegginger



Bakkeskader og flight safety

21

Monday 26/12 2005Alaska Airlines Flight 536 was 20 minutes out of Seattle and heading for Burbank, Calif., Monday afternoon when a thunderous blast rocked the plane.An investigator with the National Transportation Safety Board (NTSB) said baggage handlers had bumped the plane's fuselage with loading equipment and caused "a crease" in the side of the aircraft



22

Finn de riktige tiltakene

Do you want the green pill or the red pill?

The wrong mitigating actions can potentially make things worse



23

Safeguarding life, property and the environment

www.dnv.com

Jens Rolfsen ([email protected]) Store og små ulykker Indikatorer for styring av...

Documents

Transcript of Jens Rolfsen ([email protected]) Store og små ulykker Indikatorer for styring av...