Read the case study
Read the reflection

Leading Causes: * Oversight and ignorance of small issues - avalanche effect * Safety fatigue; Less failsafes = better fail-safing * Workers - Collaboration; shifts; handovers * Standards - Accountability

Recommendations

1) Training - if you don’t know what you’re doing, you don’t know what you’ve forgot to do. Drills, procedure

2) Reduce presence of failsafes
Reduce failsafe fatigue - overconfidence, overcomplication

3) Rehabilitation over Retribution
Reporting, review

4) Better accounting, reporting, monitoring Better procedure, stricter review of project, sensoring

Other groups:

  • Other ways to stop flow, rather than just cutting
  • Testing procedure - simulations

  • Communication

  • External audits

  • Alarm fatigue

Mentor’s Ideas:

  • Less alarms (Do all of them matter)
  • Reduce the penalty for minor infractions (Be comfortable with self reporting)