Re: [SystemSafety] Hazard analysis and The Vinci Massacre

From: Les Chambers < >
Date: Wed, 13 Jan 2016 16:30:54 +1000

It's easy to be wise after the event (when it's too late). But, if that was Iraqi I doubt that special forces would have just walked down the street in clear view of a window in a building populated by the enemy. Clearly in this case the police didn't believe that surveillance prior to the raid was warranted. The old acorn of, "it'll never happen" is one of the deadliest assumptions you can make in hazard analysis. And after the event you kick yourself for not being paranoid enough and pushing hard enough.

But this was not my point in offering this piece of theatre.

I am all for using the various hazard analysis techniques and processes that have been developed over time by functional safety professionals. But often they get so involved that normal people can't understand what you're talking about.

Overall, I'd call implementing them step two in hazard analysis sessions.

Step one is creating the emotional environment conducive to people engaging in the process. In my experience the fertile ground for hazard identification is the operational experience of those who work with the systems of interest 8 to 12 hours a day, day and night, mostly without professional supervision. These people are almost never professional analysts. Nor are they excellent at expressing themselves. In short they may lack formal education but are smart and dependable. Universally they believe more than they can prove and they know more than they can tell.

I'm constantly in search of ways of getting people who know to actually speak up and not be intimidated by professional hazard analysts who walk in the door with no operational experience but massive checklists and methodologies that look impressive on paper but ignore these simple facts. Too often I have experienced people who have never done, telling people who do, how to do.

So the objective of this eight minute scene is to convey with drama:

  1. this is a serious process
  2. getting it wrong has consequences, personal consequences
  3. we are all in this together
  4. all our opinions are valuable
  5. even if it's a hunch and you can't prove it
  6. even if its gut feel
  7. speak up we're listening

I can't stress these issues too much. I have worked with people who have got it wrong and been responsible for fatalities. Probably what triggered my interest in this video was the last minute of the scene, the image of Rachel McAdams surrounded by dead bodies, smoke and carnage, bent over, hyperventilating, mouthing every explicative she can think of ... It reminded me of a guy I met in California 1976. You could see all that in his eyes. The thing was, his incident had occurred 10 years before.  



From: paul cleary [mailto:clearmeist_at_xxxxxx Sent: Wednesday, January 13, 2016 3:22 PM To: Les Chambers
Cc: systemsafety_at_xxxxxx Subject: Re: [SystemSafety] Hazard analysis and The Vinci Massacre  


Not sure how they could have anticipated and identified those hazards, ahead of time..  

Can I ask, are you familiar with using Nodes and Guidewords as a means to conduct a structured HAZID session.  

Or would you approach HAZID without constraints, and leave nodes/guidewords for HAZOP only?  


Paul Cleary BSc, MSc, CEng, EUR ING

M + <tel:+44%20(0)7860%20861979> 44(0)7464722444  

On Jan 13, 2016, at 4:08 AM, Les Chambers <les_at_xxxxxx


Watching the HBO series: True Detectives (season 2, episode 4), it struck me that the following eight minute scene would be an excellent warmup for a hazard analysis session.

It depicts a day that starts well but just doesn't pan out the way our heroes planned.  


Pay particular attention to the last minute, beautifully dramatised as only Hollywood can.

And ask yourself, do you ever want to be in that situation because you didn't put enough time into figuring out what could go wrong and what you could do about it?  



Les Chambers
Chambers & Associates Pty Ltd


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systemsafety_at_xxxxxx Received on Wed Jan 13 2016 - 07:31:17 CET

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