TEVAPHARMA Haarlem 14 september 2010

Two kinds of safety hazards

IDirect: Loss of life, health or material lossesin modern organisations

Some chemical disastersJune 1, 1974: Flixborough disaster, England. An explosion at a chemical plant near the village of Flixborough kills 28 people and seriously injures another 36.July 10, 1976Seveso disaster, in Seveso, Italy, in a small chemical manufacturing plant of ICMESA. Due to the release of dioxins into the atmosphere and throughout a large section of the Lombard Plain, 3,000 pets and farm animals died and, later, 70,000 animals were slaughtered to prevent dioxins from entering the food chain. In addition, 193 people in the affected areas suffered from chloracne and other symptoms. The disaster lead to the Seveso Directive, which was issued by the European Community and imposed much harsher industrial regulations.December 3, 1984: TheBhopal disaster in India is the largest industrial disaster on record. A faulty tank containing poisonous methyl isocyanate leaked at a Union Carbide plant. About 20,000 people died and about 570,000 suffered bodily damage.[1] The disaster caused the region's human and animal populations severe health problems to the presentNovember 1, 1986: The Sandoz disaster in Schweizerhalle, Switzerland, releasing tons of toxic agrochemicals into the Rhine.June 28, 1988: Auburn, Indiana, improper mixing of chemicals kills four workers at a local metal-plating plant in the worst confined-space industrial accident in U.S. history; a fifth victim died two days later.[2]October 23, 1989:Phillips Disaster. Explosion and fire killed 23 and injured 314 in Pasadena, Texas. Registered 3.5 on the Richter scalSeptember 21, 2001: Toulouse, France. An explosion at the AZF fertilizer factory killed 29 and injured 2,500. Extensive structural damage to nearby neighbourhoods..

LIFE as A STRUGGLE• Typical for life is that it answers to a fundamental law,

known as Murphy’s law• IF SOMETING CAN GO WRONG, IT WILL HAPEN• So we try to develop systems in which nothing can go wrong• We normally do that by creating big, intricate and well designed

systems, by striving to be in control, to be prepared• This only works for a limited time: until Murphy strikes again• A simple solution would be not to expect anything, and to have no goals nor policies • A solution halfway the Normal and the Zen solution would be to

optimise the capacity to react to failures: Flexibility, Resilience• Resilience is the degree in which a system is able to deliver an

acceptable service level during unexpected happenings like disasters or other Murphyesque phenomena

ORGANISINGsee Karl Weick

• “Organisation” is a word for something that is not a thing • An organisation does not exist as such, it is a set of

appointments that makes happenings predictable• Humans like predictability: Therefore they make appointments,

therefore they organise• When something unexpected happens, we experiment with

different solutions: improvisation• When a solution has some promise, we promote it to a procedure• When we have several procedures, we try to integrate them in a

structure • When we have procedures and structures we give it the proud name of

ORGANISATION• But remember: When the unexpected happens, we always have to

begin with improvisation

• Accidents and crises are always unexpected

Weick’s model

The Unexpected(Equivocality)

Improvisation(Enactment)

Procedures(Selection)

Structures(Retention)

The more we progress from Enactment to Retention, the better wethink our organization is. But we know it isn’t. This is the reason why organizations strive to control their environment

The morale• The morale of this analysis is that organisations are designed to

function in a stable, predictable environment• When the unexpected happens we must fall back on

improvisation• People are not used and trained to improvise, they are used and

trained to think inside the box…..• Because in a well designed organisation everything is taken care

of and humans, as habit forming animals, easily adapt to that

• A solution may be to make the boxes so small that they just have to think outside them, but how can that be done?

• Maybe autonomous groups are the answer

Two kinds of safety hazards

IIIndirect:Loss of reputation or capital

The aftermath• Once the incident is over, your problems

aren’t• Many parties will seek redress:

– Victims from outside, aided bij lawyers– Victims from inside, also with some help– The state and its organs will try to help itself

• It would be good to prepare yourself for such an onslaught

• I will give you some simple guidelines

How strongly will the shit hit the fan?

Psf = BRM²

Psf= Power with which shit will hit fanB = Blameability of VIP or organisationR = Relevance (relative to other factors)M= Mediagenicity

Sue'em... lawsuits and information on suing chemical companies http://www.safe2use.com/lawsuit/lawsuit.htm Parents are angry about toxic products that don't work

and are taking the chemical companies to court.• As a public service, we will post each lawsuit on our

website.• Class Action Lawsuit:

• The Texas Class Action Lawsuit filed 2001 - Head Lice Products• Click here to read lawsuit and get involved

• Have you been injured by Chlordane?• Seeking justice for the poisoned?

• Click Here• If you were injured by Dursban,

• You may want to look into this class action:• http://www.classactionamerica.com/cases/case.asp?cid=764

• The California Class Action Lawsuit (4/99)• FTC (Federal Trade Commission) 9/18/98 findings.

• The Virginia Class Action Lawsuit• click here to see what happened

• Terminix - Taken to Court• Why and How the Chemical Companies control the court and media

How to cope with Blameability

How to cope with RelevanceSome general remarks

1. Pray2. Switch to a field that is less relevant

than pharmacology3. Act before their lawyers get in 4. Sit still when you’re being shaved

5. Remember that for most journalists relevance lasts three days

How to cope with the Media

• Take care that no ‘iconic’ videos or pictures can be taken

• Never get chummy with media people• Try to cooperate with media people

– Advice: Look at the situation from their side

• If you hire a PR agent, do it before anything has happened– It’s cheaper and more effective

Part III

Can we forestall these nasty situations called accidents?

Yes!!! But for that you must

analyse human behavior!!

ANALYSIS• It is to be expected that accidents will happen• Prevention is very important but not sufficient• There must also be repression• People who work at repressing the consequences of

accidents obey, just as you do, to psychological laws• An important class of these laws concerns acting

under uncertainty• We will see what training can do in this respect• Fimally we will look at distraction

Acting when the situation is uncertain• Uncertainty fosters a physio/psychological state called

arousal, a state of heightened alertness• Evolutionary seen this state is very old: reptiles and insects

also get aroused in case of danger or opportunity • Typical symptoms:

– Funnelvision (only attend to those factors of which you are uncertain), – Insensitivity to punishment and pain (which consequently do not play a role in

decision making) – Decisions more than usual are taken on the basis of habits and emotions

(normally this is already strong enough)– Tendency towards polarization: Black or White, Right or Wrong– Uncertainty leads to constant endeavours to solve it by simple intuitive

arguments. Consequently there is less capacity for more sophisticated argumentation (peripheral in stead of central information processing)

TRAINING• We try to counter the effects of arousal by training • In the best case training causes

– a. Less equivocality and uncertainty (and so less funnelvision and insensitivity for pain and punishment) 

– b. Opportunity to experience unusual emotions and thus an experience in coping with them – c. A more intense experience of qualities and personalities of coworkers. Generally this heightens

cohesion. – d. Evaluating of and ruminating on what happened during the training, promotes the construction of

arguments and argumentation that helps in a rational approach of the unexpected

• Training remains a poor substitute for experience, however realistic the training is made, but we have nothing better

• Typical for most training procedures is that they mainly aim at our rational side, but that they hardly have any effect on the very important emotional aspects of accidents and disasters

• A negative effect of good training may be that it promotes false self- assurance.

• Training together with other services (intedisciplinary) works well for the social network that promotes quick work

Effects of training• Individual:

– Emotions less dominant– Habits productive in emergency– Right arguments

• Group level:– Higher cohesion– More trust in coworkers– More mutual correction– More discussion on possibilities

• Procedural effects– Only if a thorough evaluation has taken place and results

are discussed in whole group

DISTRACTION• Effects of training are easily nullified by distraction, for instance

through new and emotional happenings [solution: training]• When coping with an emergency, one must continually try to

remember what was learned? This often means that one must do counter-intuitive things [solution: much rehearsal]

• That is not an easy thing to do, so people quickly revert to habitual action patterns [solution??]

• Of course the distraction effect is stronger in neophytes than in experienced people [solution: coupling]

• But: people with much experience think they have seen it all and thus know everything that is worthwhile and thus lose much alertness and creativity [solution: mixed teams]

• Distraction is heavily promoted by routine

What is the central lesson?

See anecdote of poor Polish man

From this story and from my short lecture the following lesson can be deduced:

Perfection is impossible, but you must keep on striving

for it

• personal protective equipment, • mass decontamination, • technical decontamination, • evidence preservation and sampling, • product control, • air monitoring and sampling, • victim rescue/recovery, and • illicit laboratory incidents