Book:Proactive Risk Management in a Dynamic Society

Proactive Risk Management in a Dynamic Society
動態情境下的主動知覺風險(與工安)管理
Authors:
            Jens Rasmussen,   professor,D.h.c.,HURECON,Denmark
            Inge Svedung,       senior lecturer,PhD,Karlstad University, Sweden
兩位作者是工安方面的達人，很多文章發表在專業期刊上，本書讓人得以一窺大師的想法與智慧
比較特別的是Rasmussen應該是心理和教育方面的背景專長，難怪可以用如此特殊的眼光與角度來看待工安事故與風險管理

風險與環安管理不該是鑑別或指責人員的疏失或抱怨制度的不合理，而是應該更積極地去思考為何會有這些罩門與意想不到的情況發生，提升自己的察覺能力、意識/認知到情境當中各項看不見卻有關係的背景因素/脈絡，進而在制度面與各項配套機制上將這些潛在背景因素與脈絡納入"管控"

這是本談論如何"治國"層次的書(一般的工安書籍談的層次大多停留在"治病")；環安與風險管理部門的主管，可以運用這本書來幫自己所服務的事業單位進行管理系統健檢與風險診斷。

點入連結即可下載pdf 檔( 全書共160頁，檔案大小約1.9M )

Table of Contents
1.Introduction 9

2.Risk management in a Dynamic Society 10
2.1 Changing Research Needs 10
2.2 The Outlines of a Proactive Strategy 15
  2.2.1 Preplanned Control 15
  2.2.2 Closed-Loop,Feedback Control 15
  2.2.3 Proactive,Closed-Loop Safety Control 15
作者所謂的動態情境(Dynamic Society)，可以用page11這張圖來呈現

而想做學術研究的話，Fig2.1其實可以當成是一幅藏寶圖=>指出在各個階層的可能研究方向。
而各階層間的不同因素，彼此相互影響與限制。
核心概念是：

1. The decision-makers and actors who are involved in the control of the productive processes at the relevant levels of the socio-technical system must be identified.
2. The part of the work-space under their control must be defined, that is, the criteria guiding the allocation of roles to the individual controllers must be found.
3. The structure of the distributed control system must be defined, that is, the structure of the communication network connecting collaborating decision-makers must be analysed.

挑戰與問題在於：
From here a number of questions related to the information available to the decision-makers and their capability of control must be considered:
4. Objectives:Are objectives and values with respect to operational as well as safety issues properly communicated within the system?
5. Status information:Are the individual decision-makers (staff,management, and regulators) properly informed about the system status in terms comparable to the objectives? In particular, are the boundaries of acceptable performance around the target-state “visible”to them?
6. Capability:Are these decision makers competent with respect to the functional properties of the organization,of the technical core and the basic safety design philosophy?
Do they know the parameters sensitive to control of performance in a changing environment?
7. Awareness:Are decision-makers prompted to consider risk in the dynamic flow of work? Are they – continuously during normal work – made aware of the safety implications of their every-day work business decisions?
8. Priorities:Are decision-makers committed to safety? Is management, for instance,prepared to allocate adequate resources to maintenance of defenses? Does regulatory efforts serve to control management priorities properly?

3.Analysis ofAccident Scenarios 17
3.1 Introduction 17
3.2 Phases of Analysis 18
  3.2.1 Accident Analysis 18
  3.2.2 Identification of Relevant Actors 19
  3.2.3 Generalization 22
  3.3.4 Preparation for Work Analysis 23
本章是本書的重點對於事故的分析與背景脈絡因素的調查很棒的解說
讓人看出造成事故的背景脈絡(或事故調查分析人員的功力淺薄？！)
分析的深淺層次感
相形比較之下，敝人先前的事故分析543 真是層次淺薄與自曝其短

4.Hazard Categories,System Types,and Risk Management 27
4.1 Accident Categories 27
4.2 The Structure of a Hazard Taxonomy 29
4.3 The Applications of a Taxonomy 29
  4.3.1 Accident Analysis 29
  4.3.2 Design of Safe Work System 29
  4.3.3 Design of Risk Management System 30
  4.3.4 Design ofAuditing Systems. 30
  4.4 Characteristics of Causal and Relational Representations 30
  4.4.1 Structural Decomposition 30
  4.4.2 Functional Abstraction 31
  4.4.3 Illustrative Examples 31
哇，行家一出手便知有沒有，
作者對於危害的分類不是嚴重對頻率的四大象限，亦或物理性、化學性/生物性等
而是以下這張圖
看不懂的，建議可以先參考拙作 工安風險的樣貌與估計

 

5.The Taxonomy Framework 33
5.1 a. Target of Hazard 34
     a. 1. Individual Actor 34
     a. 2. Staff 34
     a. 3. Environment 34
     a. 4. Harm to General Public 34
     a. 5. Loss of Investment 34
5.1 b. Physics of Hazard Source 34
     b. 1. Energy Accumulations 34
     b. 2. Accumulation of Toxic Substances 35
     b. 3. Structural Integrity and Stability 35
     b. 4. Others,Mixed 35
5.1 c. Means for Safety Control 35
    c. 1. Reinforce Hazard Containment 37
    c. 2. Fight Causes of Hazard Release 37
    c. 3. Control Effects after Release of Hazard 40
    c. 4. Decrease Impact of Released Hazard 43
5.1 d. The Cover Story 43
5.2 Conclusion 43

第4、5章可當成是第3章的延伸，而這章fig5.2、5.3、5.11& table5.1是精髓

6.Preconditions of Proactive Risk Management Systems 47
6.1 Safety Viewed as a Control Problem 47
   6.1.1 Proactive Safety Control 47
   6.1.2 Measuring Safety 48
6.2 Support of Operation within the Design Envelope 49
   6.2.1 Explicit Formulation of the Boundaries of Safe Operation 49
   6.2.2 Communication of Design Envelope to Operating Organization 49
   6.2.3 Risk Management should be Part of Operational Line Management 49
   6.2.4 Design ofManagers’ Information System Interface 49
這章很短、迷你，看來式編排上的敗筆與作者不是實務界的後遺症，不然其實有很多可以著墨的業界範例可以放進來


7.Design of Proactive Risk Management Support System 50
7.1 Identification of Decision Makers 51
7.2 Identification of Control Space: Role Allocation 52
   7.2.1 The Functional Organization 54
   7.2.2 The Social Aspects of Organization 55
7.3 The Structure of the Control System and the Communication Network 55
7.4 Identification of the Flow of Control Information 57
   7.4.1 Objectives and Criteria 57
   7.4.2 Information on Actual State ofAffairs 59
7.5 The Capability of Decision Makers 59
   7.5.1 Forms of Competence 60
   7.5.2 Competence at the Skill-based Level. 61
   7.5.3 Competence at the Rule-based Level 61
   7.5.4 Competence at the Knowledge-based Level 62
   7.5.5 A Note on the Nature of Human Error 63
7.6 Awareness 63
7.7 Commitment 64
7.8 Design of Work Interfaces 64
   7.8.1 The Conceptual Content of a Display 65
   7.8.2 The Scope of the Interface Representation 65
   7.8.3 Transformation from Relational to Causal Representation 65
   7.8.4 The Form of Display Representation 65
7.9 Auditing Scenarios: Examples 66
   7.9.1 Process Plants 69
這章也是重點和精華，理工背景的讀者請耐著性子體會一下這種非線性、"牽連互動"的系統思維方式；這種思維的fu 跟第五項修練那本書很類似：都是在試著離清造成問題的複雜因果關連，找出事半功倍的槓桿解。

8.Risk and Quality Management Approaches 72
8.1 Certification 73
8.2 Conclusion 73
這章的評論與第6張相同
然而作者對於所謂管理系統認知與概念為人員角色與組織運作流程導向：

Identification of Decision-Makers.
Allocation of Roles.
Identification of the Control Structure.
Flow of Control Information.
Controller Capability and Awareness.
Controller Commitment

而非一般的程序文件導向，習慣看ISO系統條文的讀者須注意到以上觀點差異

9.Tool for Accident Analysis and Organisational Audit 74
9.1 An outline of a Tool 75
9.1.1 Entrance to the Guide 75
9.1.2 Definition ofAccident Situation 76
9.1.3 Analysis ofAccident Situation 76
9.1.4 Query Guide 77
9.1.5 Information Source Questionnaire 78
9.1.6 Decision Making Questionnaire 78
9.2 Requirements on a computer based Tool 81
9.2.1 Structure of Data Collection 81
9.2.2 The Platform program 82
9.3 The Interface 86
9.3.1 The interface of the “on the scene”reporting Tool 86
9.3.2 The interface of the Tool for Subsequent Audit 86
這個部份的內容，參與過稽核業務和經驗應該都不會有進入障礙，說穿了就是路徑稽核的手法，套用以上的觀念架構設定問項與準備

10.Emergency Management and Rescue Services 87
10.1 Assumptions Embedded in the Planning Model 87
10.2 Consequences of the Planning Model 87
10.3 Toward a More Adequate Planning Model 88
10.4 Information Systems for Emergency management 89
10.5 Workspace Representation 90
10.6 The Use of the Workspace Representation 92
10.7 Decision Support 92
10.8 Rescue Commanders’point of View 96
  10.8.1 Route Information. 97
  10.8.2 Access to the accident site 97
  10.8.3 Capacity of hospitals 97
  10.8.4 Plant descriptions 97
  10.8.5 Sewers 97
  10.8.6 Chemical expertise 97
  10.8.7 Medical expertise 97
  10.8.8 Technical expertise 97
這個部份，前面的部份比較像企業營運持續計劃(BCP)而非緊急應變，然而後面10.8的部份卻又像緊急應變而非BCP；或許個人在這方面涉獵與經驗稍多，所以覺得這個章節寫得不痛不癢。

11.Example of a detailed Field Study 99
11.1 The Context 100
  11.1.1 Warehouse and utilities 100
  11.1.2 Production 100
  11.1.3 Functions performed 101
11.2 Organization / Roles of actors 102
11.3 Flow of information 103
11.4 Goals and Strategies of Goods Handler 104
  11.4.1 Goals 104
  11.4.2 Strategies 105
  11.5 Delivery Deficiencies 107
    11.5.1 Type of Deficiencies 107
    11.5.2 Number of deficiencies 108
11.6 Implementation of a feed back routine for complaints 111
11.7 Effect over time of the feed-back routine 111
11.8 Normal work of a warehouseman / an ActivityMap 112
很棒的案例，讓人更清楚前面一堆形而上的觀念與因素，實際上是怎麼樣
能否把服務公司內各項流程弄清楚整理成這章的圖表，對於風險管理人員是一大考驗與檢定是否足夠"敬業"

Appendix A:Accident Scenarios
Appendix B: Structure ofAccident Data Collection
附錄的部份也值得參考，亦非放一些塞不進前述章節的枝節


總結：
瑕不掩瑜的超讚好書，從組織運作面與系統觀點切入，讓人看到技術/直線邏輯的盲點。
有幸與一位技術超強的工安夥伴共事(在他經歷過不少上報與沒上報的職災，或許也正是這些真正的實戰血淚，塑造了他的功力)，他常說：真正大條的工安事故會發生，都是出在界面問題上(硬體設備系統的交接處或組織部門權責的三不管地帶)；
對於如何分析、鑑別與處理/防範這些界面問題，這本書提供了很好的指引與思考方向。

我要拿書中的內容來虐待玩弄教育提升共事的夥伴了！

希望能夠安居樂業，繼續當一個沒出過大事、只會嘴砲和唬爛的環安主管。