Serious event prevention: Setting the stage for real change

摘要

FOLLOWING THE 1988 Piper Alpha disaster that killed 167 workers, the controlling company's CEO infamouslyresponded, "We have done all we can to prevent catastrophic failures like this one." More than two decades later, belief in the inevitability of serious injury and fatality (SIF) events is still commonplace. We often hear leaders say "accidents sometimes happen," or "we don't know where these events are coming from." These leaders aren'tcallous. Many are deeply troubled by the persistence of SIF events, particularly as the rate of less severe injuries continues to fall. What's really happening is that leaders have been hamstrung by a paradigm that misrepresents the nature of SIF events.