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June 4, 2018
8:30-9:30AM

Process Safety and Safety-II in CSB Investigations

Expo A1

Speaker: Steven Cutchen, Investigator, U.S. Chemical Safety Board

Safety-I regards incidents as caused by technical, human, and organizational failures. People are error-prone, treated as a liability or hazard. Outcome bias becomes the basis for cause. Hindsight bias creates blame. Operational Discipline becomes Discipline of Operators.

Safety-I does not explain why human performance practically always goes right. In complex systems, people adjust their work to actual conditions, what makes sense at the moment. Success signifies Resilience.

Safety-II changes the target from “as few things as possible go wrong’” to “as many things as possible go right.” Rather than thinking of people as error-prone liabilities, in Safety-II they are recognized as necessary for resilience. Risk assessment includes searching for the boundaries where procedural controls become ineffective. Safety management anticipates perturbations and consequences. Investigation determines how things normally go right, and what was different this time.

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2018-06-04 08:30:00 2018-06-04 09:30:00 America/Detroit Process Safety and Safety-II in CSB Investigations Speaker: Steven Cutchen, Investigator, U.S. Chemical Safety Board Safety-I regards incidents as caused by technical, human, and organizational failures. People are error-prone, treated as a liability or hazard. Outcome bias becomes the basis for cause. Hindsight bias creates blame. Operational Discipline becomes Discipline of Operators. Safety-I does not explain why human performance practically always goes right. In complex systems, people adjust their work to actual conditions, what makes sense at the moment. Success signifies Resilience. Safety-II changes the target from “as few things as possible go wrong’” to “as many things as possible go right.” Rather than thinking of people as error-prone liabilities, in Safety-II they are recognized as necessary for resilience. Risk assessment includes searching for the boundaries where procedural controls become ineffective. Safety management anticipates perturbations and consequences. Investigation determines how things normally go right, and what was different this time. Expo A1