Notes

Slide Show

Outline

1	Interface Between Engineering and Biology and its Impact on the Human Condition: Avoiding Unintended Consequences
2	unintended consequences
3
4
5	Organizations have major influences
6
7
8
9
10
11
12
13
14
15	Operator malfunctions Communications Violations Limitations Slips Ignorance Flawed planning Mistakes
16	"Culture" Culture Communications Violations Organization Monitoring Leading
17	Procedure malfunctions Incorrect Inaccurate Incomplete Excessive complexity Poor documentation
18	Hardware malfunctions Serviceability Compatibility Durability Safety
19
20
21	Proactive: - High Reliability Organizations Extensive process auditing Risk mitigating reward systems Higher quality standards Risk perception - early warnings Command & control systems
22	Command and control Systems Migrating decision making Robustness - defect & damage tolerant Maintaining the ‘bubble’ Formal rules and procedures Selection & training - the ‘right stuff’
23
24	Not who is to blame! But, what defense systems broke down?
25	Blunt end - organizations Sharp end - operators
26	Interactive: the “right stuff”
27	Deployment of resources
28	Success factors = 5 C’s Commitment - top down and bottom up Capability - sensitivity and technical / management abilities Cognizance - awareness of hazards & risks Culture - quality & reliability Counting - measures created to recognize tangible financial and intangible benefits
29	avoiding unintended consequences is one damn thing after another!