Outcomes are so sexy and attractive…

In the mid-1980s, there was a flight safety film produced which showed a Royal Air Force pilot walking out to his single-seat Jaguar fighter aircraft for a training sortie. He prepares the aircraft, starts it up and takes-off down the runway. Unfortunately, the aircraft has an engine failure immediately after take-off, but the pilot can’t jettison the external stores, and crashes and he dies because the aircraft doesn’t have enough power to fly on a single-engine given its full fuel load and the heavy external stores. It transpires that during the pre-take-off checks, the pilot forgot to arm the stores jettison system, and even though he is trying to jettison them, they won’t go because there is a safety system in place to stop an inadvertent release. It would be quite easy to blame this highly trained and professional pilot for forgetting to do something which was part of his pre-take-off checklist. However, the Royal Air Force recognised that it takes many things...

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Listy kontrolne CCR, nie zapewniają niezawodności sprzętu

„Jednym z kluczowych zagadnień których uczę, jest zrozumienie, że bezpieczeństwo nie musi oznaczać braku awarii czy wypadków, a raczej jest to istnienie reguł i zabezpieczeń oraz wydolność systemu czy organizacji do przetrwania awarii w sposób bezpieczny”. To cytat autorstwa Todda Conklina, badacza i praktyka z branży bezpieczeństwa i wydajności w Stanach Zjednoczonych. Chodzi o to, że rozwijamy umiejętności techniczne i nietechniczne oraz projektujemy sprzęt, procedury i szkolenia oraz zarządzamy środowiskiem w taki sposób, aby można było zarządzać ryzykiem na akceptowalnym poziomie. Nie jesteśmy jednak w stanie zaprojektować ani zarządzać wszystkim, nie wszystko można przewidzieć, więc musimy być w stanie poradzić sobie z tymi „niezaplanowanymi zdarzeniami”, a następnie udostępnić historię tego co się wydarzyło, aby inni mogli się z tego uczyć.

W nurkowaniu na obiegu zamkniętym jednym z najlepszych sposobów zapewnienia...

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Only 20% of surgeons would like to use a checklist in their operations…

…but 94% would like one used in an operation on themselves…!
 
Atul Gawande gave four presentations before Christmas as the 2014 Reith Lectures’ presenter (BBC iPlayer downloads and transcripts can be downloaded from here).
 
During these presentations, he highlighted ways in which the healthcare and medical industries could develop their safety further, but he also recognised that we are all human, fallible and therefore there was a limit to what could be achieved and, consequently we needed to recognise this when judging adverse outcomes.  The same situation needs to be recognised within sports diving where we are undertaking an activity (of our choice) which has an inherent risk of fatality as we are in a hostile, non-life sustaining environment if something serious goes wrong.
 
His second presentation specifically looked at how better systems could improve safety, and radically reduce the mistakes and errors made, and improve...
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