Risk Book from C.H.I.P.S.

Managing Risk
The Human Element
by Romney B. Duffey

Managing Risk combines descriptive and explanatory text with theoretical and mathematical analysis, offering important new concepts that can be used to improve the management of risk, trend analysis and prediction, and hence affect the accident rate in technological industries.

Managing Risk is an essential read for professional safety experts, human reliability experts and engineers in all technological industries, as well as risk analysts, corporate managers and statistical analysts.


1. The Universal Learning Curve

  • Predicting Tragedies, Accidents and Failures: Using the Learning Hypothesis
  • The Learning Hypothesis: The Market Place of Life
  • Learning in HTSs: The Way a Human Learns
  • Evidence of Risk Reduction by Learning
  • Evidence of Learning from Experience: Case Studies
  • Evidence of Learning in Economics
  • Evidence of Learning in Engineering and Architecture: The Costs of Mistakes
  • Learning in Technology: the Economics of Reducing Costs
  • Evidence of Learning Skill and Risk Reduction in the Medical Profession: Practice Makes Almost Perfect
  • Learning in HTSs: The Recent Data Still Agrees
  • The Equations That Describe the Learning Curve
  • Zero Defects and Reality
  • Predicting Failures: The Human Bathtub
  • Experience Space: The Statistics of Managing Safety and of Observing Accidents
  • Predicting the Future Based on Past Experience: The Prior Ignorance
  • Future Events: the Way Forward Using Learning Probabilities
  • The Wisdom of Experience and Inevitability
  • The Last, First or Rare Event
  • Conclusions and Observations: Predicting Accidents
2. The Four Echoes

  • Power Blackouts, Space Shuttle Losses, Concorde Crashes, and the Chernobyl and Three Mile Island Accidents
  • The Combination of Events
  • The Problem Is the Human Element
  • The Four Echoes Share the Same Four Phases
  • The First Echo: Blackout of the Power Grid
  • Management’s Role
  • The First Echo: Findings
  • Error State Elimination
  • The Second Echo: Columbia/Challenger
  • The Results of the Inquiry: Prior Knowledge
  • The Second Echo: The Four Phases
  • Management’s Responsibility
  • Error State Elimination
  • The Third Echo: Concorde Tires and SUVs
  • Tire Failures: the Prior Knowledge
  • The Third Echo: The Four Phases
  • Management’s Responsibility
  • Error State Elimination
  • The Fourth Echo: Chernobyl
  • The Chernobyl Accident: An Echo of Three Mile Island
  • The Consequences
  • Echoes of Three Mile Island
  • The Causes
  • Error State Elimination
  • The Fourth Echo: The Four Phases
  • Regulatory Environment and Practices
  • Addressing Human Error
  • Management Responsibilities
  • Designing to Reduce Risk and the Role of Standards
  • Conclusion and Echoes: Predicting the Unpredictable
3. Predicting Rocket Risks and Refi nery Explosions: Near Misses, Shuttles, Safety and Anti-Missile Defence Systems Effectiveness

  • Learning from Near Misses and Prior Knowledge
  • Problems in Quantifying Risk: Predicting the Risk for the Next Shuttle Mission
  • Estimating a Possible Range of Likelihoods
  • Learning from Experience: Maturity Models for Future Space Mission Risk
  • Technology versus Technology
  • Missiles Risks over London: The German Doodlebug
  • Launching Missile Risk
  • The Number of Tests Required
  • Estimating the Risk of a Successful Attack and How Many Missiles We Must Fire
  • Uncertainty in the Risk of Failing to Intercept
  • What Risk Is There of a Missile Getting Through: Missing the Missile
  • Predicting the Risk of Industrial Accidents: The Texas City Refinery Explosion
  • From Lagging to Leading: Safety Analysis and Safety Culture
  • Missing Near Misses
  • What these Risk Estimates Tell Us: The Common Sense Echo
4. The Probability of Human Error: Learning in Technological Systems

  • What We Must Predict
  • The Probability Linked to the Rate of Errors
  • The Definition of Risk Exposure and the Level of Attainable Perfection
  • Comparison to Conventional Social Science and Engineering Failure and Outcome Rate Formulations
  • The Learning Probabilities and the PDFs
  • The Initial Failure Rate and its Variation with Experience
  • The ‘Best’ MERE Risk Values
  • Maximum and Minimum Likely Outcome Rates
  • Standard Engineering Reliability Models Compared to the MERE Result
  • Future Event Estimates: The Past Predicts the Future
  • Statistical Bayesian-Type Estimates: The Impact of Learning
  • Maximum and Minimum Likelihood
  • Comparison to Data: The Probability of Failure and Human Error
  • Comparison of the MERE Result to Human Reliability Analysis
  • Implications for Generalised Risk Prediction
  • Conclusions: The Probable Human Risk
5. Eliminating Mistakes: The Concept of Error States

  • A General Accident Theory: Error States and Safety Management
  • The Physics of Errors
  • The Learning Hypothesis and the General Accident Theory
  • Observing Outcomes
  • A Homage to Boltzmann: Information from the Grave
  • The Concept of Depth of Experience and the Theory of Error States
  • The Fundamental Postulates of Error State Theory
  • The Information in Error States: Establishing the Risk Distribution
  • The Exponential Distribution of Outcomes, Risk and Error States
  • The Total Number of Outcomes
  • The Observed Rate and the Minimum Number of Outcomes
  • Accumulated Experience Measures and Learning Rates
  • The Average Rate
  • Analogy and Predictions: Statistical Error Theory and Learning Model Equivalence
  • The Infl uence of Safety Management and Regulations: Imposing Order on Disorder
  • The Risk of Losing a Ship
  • Distribution Functions
  • The Most Probable and Minimum Error Rate
  • Learning Rates and Experience Intervals: The Universal Learning Curve
  • Reducing the Risk of a Fatal Aircraft Accident: the Infl uence of Skill and Experience
  • Conclusions: A New Approach
6. Risk Assessment: Dynamic Events and Financial Risks

  • Future Loss Rate Prediction: Ships and Tsunamis
  • Predicted Insurance Rates for Shipping Losses: Historical Losses
  • The Premium Equations
  • Financial Risk: Dynamic Loss and Premium Investments
  • Numerical Example
  • Overall Estimates of Shipping Loss Fraction and Insurance Inspections
  • The Loss Ratio: Deriving the Industrial Damage Curves
  • Making Investment Decisions: Information Drawing from the Jar of Life
  • Information Entropy and Minimum Risk
  • Progress and Learning in Manufacturing
  • Innovation in Technology for the Least Product Price and Cost: Reductions During Technological Learning
  • Cost Reduction in Manufacturing and Production: Empirical Elasticity ‘Power Laws’ and Learning Rates
  • A New General Formulation for Unit Cost Reduction in Competitive Markets: the Minimum Cost According to a Black-Scholes Formulation
  • Universal Learning Curve: Comparison to the Usual Economic Power Laws
  • The Learning Rate b-Value ‘Elasticity’ Exponent Evaluated
  • Equivalent Average Total Cost b-Value Elasticity
  • Profit Optimisation to Exceed Development Cost
  • The Data Validate the Learning Theory
  • Non-Dimensional UPC and Market Share
  • Conclusions: Learning to Improve and Turning Risks into Profits
7. Safety and Risk Management Systems: the Fifth Echoes

  • Safety Management Systems: Creating Order Out of Disorder
  • Workplace Safety: The Four Rights, Four Wrongs and Four Musts
  • Acceptable Risk: Designing for Failure and Managing for Success
  • Managing and Risk Matrices
  • Organisational Factors and Learning
  • A Practical ‘Safety Culture’ Example: The Fifth Echo
  • Safety Culture and Safety Surveys: The Learning Paradox
  • Never Happening Again: Perfect Learning
  • Half a World Apart: Copying the Same Factors
  • Using a Bucket: Errors in Mixing at the JCO Plant
  • Using a Bucket: Errors in Mixing at the Kean Canyon Explosives Plant
  • The Prediction and Management of Major Hazards: Learning from SMS Failures
  • Learning Environments and Safety Cultures: The Desiderata of Desires
  • Safety Performance Measures: Indicators and Balanced Scorecards
  • Safety and Performance Indicators: Measuring the Good
  • Human Error Rates Passing Red Lights, Runway Incursions and Near Misses
  • Risk Informed Regulation and Degrees of Goodness: How Green is Green?
  • Modelling and Predicting Event Rates and Learning Curves Using Accumulated Experience
  • Using the Past to Predict the Future: How Good is Good?
  • Reportable Events
  • Scrams and Unplanned Shutdowns
  • Common Cause Events and Latent Errors
  • Performance Improvement: Case-by-Case
  • Lack of Risk Reduction: Medical Adverse Events and Deaths
  • New Data: Sentinel Events, Deaths and Blood Work
  • Medication Errors in Health Care
  • Organisational Learning and Safety Culture: the ‘H-Factor’
  • Risk Indicator Data Analysis: A Case Study
  • Meeting the Need to Measure Safety Culture: the Hard and the Soft Elements
  • Creating Order from Disorder
8. Risk Perception: Searching for the Truth Among all the Numbers

  • Perceptions and Predicting the Future: Risk Acceptance and Risk Avoidance
  • Fear of the Unknown: The Success Journey into What We Do or Do Not Accept
  • A Possible Explanation of Risk Perception: Comparisons of Road and Rail Transport
  • How Do We Judge the Risk?
  • Linking Complexity, Order, Information Entropy and Human Actions
  • Response Times, Learning Data and the Universal Laws of Practice
  • The Number and Distribution of Outcomes: Comparison to Data
  • Risk Perception: Railways
  • Risk Perception: Coal Mining
  • Risk Perception: Nuclear Power in Japan
  • Risk Perception: Rare Events and Risk Rankings
  • Predicting the Future Number of Outcomes
  • A Worked Example: Searching out and Analysing Data for Oil Spills
  • Typical Worksheet
  • Plotting the Data
  • Fitting a Learning Curve
  • Challenging Zero Defects
  • Comparison of Oil Spills to other Industries
  • Predicting the Future: the Probability and Number of Spills
  • Observations on this Oil Spill Case
  • Knowing What We Do Not Know: Fear and Managing the Risk of the Unknown
  • White and Black Paradoxes: Known Knowns and Unknown Unknowns
  • The Probability of the Unknowns: Learning from What We Know
  • The Existence of the Unknown: Failures in High Reliability Systems
  • The Power of Experience: Facing Down the Fear of the Unknown
  • Terrorism, Disasters and Pandemics: Real, Acceptable and Imaginary Risks
  • Estimating Personal Risk of Death: Pandemics and Infectious Diseases
  • Sabotage: Vulnerabilities, Critical Systems and the Reliability of Security Systems
  • What Is the Risk?
  • The Four Quadrants: Implications of Risk for Safety Management Systems
9. I Must Be Learning

  • Where We Have Come From
  • What We Have Learned
  • What We Have Shown
  • Legal, Professional and Corporate Implications for the Individual
  • Just Give Me the Facts
  • Where We Are Going


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Managing Risk
The Human Element
by Romney B. Duffey

2008 • 539 pages • $150.00 + shipping
Texas residents please add 6.75 % sales tax

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