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Risk Summit 2011. Integrating Safety Into Operations A Systems Thinking Approach ACTIVITY. Charles Gray, CSP, CPEA Janette de la Rosa Ducut , Ed.D . Ground Rules. Answers. $100 Accident Investigation. There’s no such thing as one of these. Root Cause. $200 Accident Investigation.

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risk summit 2011

Risk Summit 2011

Integrating Safety

Into Operations

A Systems Thinking Approach ACTIVITY

Charles Gray, CSP, CPEA

Janette de la Rosa Ducut, Ed.D.

100 accident investigation
$100Accident Investigation

There’s no such thing

as one of these.

Root Cause

200 accident investigation
$200Accident Investigation

To be effective,

drive out fear and this.


300 accident investigation
$300Accident Investigation

A milk-based food product that was used by James Reason to create a model of accident causation; suggesting that systemic failures occur from a series of events at different layers of an organization.

Swiss Cheese Model

400 accident investigation
$400Accident Investigation

Accidents do not occur due to single human _____.


500 accident investigation
$500Accident Investigation

Focus on interrelationships and processes and avoid this type of chain.


100 case studies
$100Case Studies

U.S. Presidentduring the 1980swho declared that that space shuttle was “fully operational”, increasing pressure on NASA.

Ronald Reagan

200 case studies
$200Case Studies

The name used to describe NASA’s safety program during the Challenger accident investigations.

Silent Safety Program

300 case studies
$300Case Studies

The standard computer part that does not fit every hand.


400 case studies
$400Case Studies

The number of launches per month that was scheduled for 1986, resulting in risky decisions.

2 launches per month

500 case studies
$500Case Studies

The ergonomic injury is an example of how (financial) structure drives this.


100 systems theory
$100Systems Theory

Systems thinking encourages us to look at the bigger _____.


200 systems theory
$200Systems Theory

A system can be defined as the interaction between people, their machines, and this component.


300 systems theory
$300Systems Theory

This insect on a beachwas a metaphor thatNobel laureate Herbert Simon used to illustrate the powerful role of the environment on individual behavior.


400 systems theory
$400Systems Theory

Rather than specific events,look for overall structures, patterns, and these.


500 systems theory
$500Systems Theory

Author of the bookThe Fifth Discipline

Peter Senge

100 uc trivia
$100UC Trivia

The official number of campuses in the UC system.

10 campuses

200 uc trivia
$200UC Trivia

Names of the three national laboratories that the UC manages.

  • Lawrence Berkeley National Laboratory (LBNL)
  • Lawrence Livermore National Laboratory (LLNL)
  • Los Alamos National Laboratory (LANL)
300 uc trivia
$300UC Trivia

Location of the five medical centers in the UC system.

  • Davis
  • Irvine
  • Los Angeles
  • San Diego
  • San Francisco
400 uc trivia
$400UC Trivia

This statewide network of UC researchers and educators dedicated to the creation, development, and application of agricultural, natural, and human resources is known by the acronym “ANR”.

Agriculture and Natural Resources

500 uc trivia
$500UC Trivia

Designers of the original artwork for the UC seal, which was destroyed during the (1906) San Francisco earthquake and fire.

Tiffany & Co.