Human Error - Fresh Thinking for Managing Non-Compliant Behaviors

摘要

1912. The RMS Titanic steams toward a known ice field while maintaining close to full speed… 1986. The Challenger space shuttle takes off despite a known problem with a critical component requiring NASA to circumvent and by-pass its own safety rules to make the launch time. 1987: The "Herald of Free Enterpris"e a roll-on/roll-off car ferry leaves the port of Zeebrugge in Belgium with its bow door open. This is not an uncommon practice when ferry crossings fall behind schedule. 2005. Operators at the Texas City refinery routinely overfill a distillate column as part of normal start- up practices, even though this is seen as an unacceptable procedural violation. 2010. The offshore drillship "Deepwater-Horizon" is seriously behind schedule on the Macondo well and with ever rising operating costs, there is an immediate desire to finish the job. And while the crews have been congratulated for a "safe job", the same can't be said of key barriers to prevent catastrophic loss. What do these all have in common? Simple… Human Error: Despite spanning almost a hundred years, in each and every case, the past experience of those involved conspired with an operating culture that had "normalize"d elevated levels of risk. Any yet, when disaster stuck, it was met with utter disbelief and questions around how this could possibly have ever happened.