Managers in the organization manage risk with systematic and structured processes intended to limit the assessed risk. But, even in the best organizations, when it is time to go to work, operators don’t manage risk; they control risk. To work effectively and stay alive, the front-line workers need operating techniques for controlling risk to supplement the structured rules and procedures promulgated by managers to manage risk.
This is a book about controlling risk. After almost forty years in hazardous endeavors, I have learned the techniques I use to control risk not only help me stay alive, a fairly nice incentive, but they also help me accomplish more missions in better ways. These are the same techniques necessary for operating excellence, which results in higher performance and greater success for me as an operator, and more profits and maximized long-term productivity for my organization. When really understood and embraced as a way of operating, these techniques enable groups of people working together to optimize results in any high-risk business and accomplish more in our dangerous world—or out of this world.
Since becoming a naval aviator, I have been on a continuous journey of learning how to prevent the next accident that is inevitably trying to injure or kill me.
Every potential accident gives signals before it becomes an accident. To enhance our chance of preventing catastrophe, we must learn to discern these signals. To do this, we study history. We analyze previous organizational failures and catastrophes. Root cause specialists identify problems that, if corrected, create a higher likelihood of preventing future occurrences of similar tragedies. With experience, we learn to prevent accidents.
But can we predict all accidents from observing the past? Are some unpreventable? We easily prevent potential accidents that are similar to recent occurrences, but preventing accidents that exceed corporate experience seems extraordinarily difficult. Organizations continue to be blindsided by tragedies that no one thought would occur. Yet, in any given postincident analysis, investigators often determine the latest catastrophe was tragically similar to a forgotten previous incident. New rules are promulgated, operating procedures are updated—and the cycle of accidents continues. Organizations must need something more than rules and procedures to prevent accidents.
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