Sponsored by ASEM - IISE/SEMS - CAE- ABEPRO
Error Management - Management Practices of Learning From Errors in High Risk Industries
Accidents are caused by multiple causes, influence factors, conditions that occur at a variety of sociotechnical levels (equipment failure, staffing inadequacy, deficient management, lack of regulatory oversight) along a timeline that can last for years. Indeed, latent failures, weak signals, precursors, near-misses, alerts, are not treated accordingly. Lessons from industrial accidents show that failures to learn are one of the recurring root and systemic causes of accidents. Starting from these lessons, the stakes, challenges and requirements are identified and can be adapted. They are discussed with regards to some good practices and recent changes in some high-risk industries.
Nicolas Dechy is currently employed at the French National Institute of Nuclear Safety and Radiation Protection (IRSN) that provides expertise to the regulator. He conducts organizational and human factors assessment of safety and radiation protection management of maintenance activities, subcontracting, and emergency response in the aftermath of Fukushima. As an engineer, he has expert experience in the field of accident investigation (Toulouse disaster), chemical risk assessment, emergency response and crisis management in process safety (Seveso). He has conducted several assessments, studies, engineering and researches on learning from experience especially on failures and barriers to learn with European Safety and Reliability Data Association and Institut pour la maîtrise des risques association.This webinar is the fourth in a four-part series.
What happens if someone makes a mistake or takes the wrong decision? The issue here is not intentional misconduct, fraudulent behaviour, gross negligence or large-scale mismanagement, but the little mistakes, errors and poor decisions that occur every single day. Mostly, errors are the result of momentary blackouts, a temporary short circuit in the brain, false impressions, deceptive memories, dots wrongly joined, fragments of conversation that we interpret incorrectly, prejudices, momentary feelings of mental imbalance, disorientation, stress and other disturbances.
What does this mean for larger organizations? From research we know that speaking-up when spotting errors is not the norm in organizations. Mistakes are still associated with shame and embarrassment. Yet factual error management can work and be successful as can be seen by studying high reliability organizations such as aviation, medicine, and the nuclear industry.
In the webinar series on error management we will look into the practices and learnings from these high reliability organizations. Apart from the specifics of the different industries we will reflect on what is necessary to establish an effective open error culture. This includes psychological safety to enable communication across hierarchical levels, a system of error reporting, a leadership culture, where people are empowered to speak up, and how humans interact in complex systems.
The speakers are either researchers or practitioners and provide insights into lessons learned from their field. The series will explore how these learnings may be applied in other organizations.
The webinar series is scheduled as follows. Please note that EACH webinar has its own URL for registration.
June 20 - Introduction to error management (Jan Hagen, ESMT Berlin) - 1:00 PM EDT
Register here: https://www.asem.org/event-2566166
July 11 - Error management and reporting culture in aviation (Thomas Wilpert, Air Berlin) - 1:00 PM EDT
Register here: https://www.asem.org/event-2568371
July 25 - Empowerment as tool for error management in medicine (Jan Brommundt, University Medical Center Groningen) - 1:00 PM EDT
Register here: https://www.asem.org/event-2568393
August 8 - Management practices of learning from errors in high risk industries (Nicolas Dechy, Institut de Radioprotection et de Sûreté Nucléaire) - 1:00 PM EDT
Register here: https://www.asem.org/event-2568621