engineering a safer world systems thinking applied to safety

[...]... Organizational Components of the Safety Control Structure 231 8.6.1 Programmatic and Organizational Risk Analysis 231 8.6.2 Gap Analysis 232 8.6.3 Hazard Analysis to Identify Organizational and Programmatic Risks 235 8.6.4 Use of the Analysis and Potential Extensions 238 8.6.5 Comparisons with Traditional Programmatic Risk Analysis Techniques 239 8.7 Reengineering a Sociotechnical System: Pharmaceutical Safety. .. risk management is to identify and analyze the conflicts, to make appropriate tradeoffs among the conflicting requirements and constraints, and to find ways to increase system safety without decreasing system reliability Safety versus Reliability at the Organizational Level So far the discussion has focused on safety versus reliability at the physical level But what about the social and organizational... to prevent accidents are described in chapter 16 of Safeware One obvious example is systems that are fail-safe, that is, they are designed to fail into a safe state For an example of behavior that is unreliable but safe, consider human operators If operators do not follow the specified procedures, then they are not operating reliably In some cases, that can lead to an accident In other cases, it may... conflicting goals ATC systems commonly have the mission to both increase system throughput and ensure safety One way to increase throughput is to decrease safety margins by operating aircraft closer together Keeping the aircraft separated adequately to assure acceptable risk may decrease system throughput There are always multiple goals and constraints for any system—the challenge in engineering design and risk... examples, and other teaching and learning aids and provide them for download from a website in the future Chapters 6–10, on system safety engineering and hazard analysis, are purposely written to be stand-alone and therefore usable in undergraduate and graduate system engineering classes where safety is just one part of the class contents and the practical design aspects of safety are the most relevant... accident causation and system safety techniques that resulted The solution, I believe, lies in creating approaches to safety based on modern systems thinking and systems theory While these approaches may seem new or paradigm changing, they are rooted in system engineering ideas developed after World War II They also build on the unique approach to engineering for safety, called System Safety, that was pioneered... efforts are based are inadequate for the complex systems we are building today The world of engineering has experienced a technological revolution, while the basic engineering techniques applied in safety and reliability engineering, such as fault tree analysis (FTA) and failure modes and effects analysis (FMEA), have changed very little Few systems are built without digital components, which operate very... of systems and hazards we are dealing with today This book shows how systems theory and systems thinking can be used to extend our understanding of accident causation and provide more powerful (and surprisingly less costly) new accident analysis and prevention techniques It also allows a broader definition of safety and accidents that go beyond human death and injury and includes all types of major... Relationship to Safeware My first book, Safeware, presents a broad overview of what is known and practiced in System Safety today and provides a reference for understanding the state of the art To avoid redundancy, information about basic concepts in safety engineering that appear in Safeware is not, in general, repeated To make this book coherent in itself, however, there is some repetition, particularly... and sometimes even they have incomplete information about the system’s potential behavior The problem is that we are attempting to build systems that are beyond our ability to intellectually manage; increased complexity of all types makes it difficult for the designers to consider all the potential system states or for operators to handle all normal and abnormal situations and disturbances safely and