EBC2100 – Crisis Management in Organisations
Tutorial 1....................................................................................................................................................... 1
Tutorial 1 Summary....................................................................................................................................... 4
Tutorial 2..................................................................................................................................................... 12
Tutorial 2 Summary..................................................................................................................................... 16
Tutorial 3..................................................................................................................................................... 26
Tutorial 3 Summary..................................................................................................................................... 35
Tutorial 4..................................................................................................................................................... 44
Tutorial 4 Summary..................................................................................................................................... 56
Tutorial 5..................................................................................................................................................... 64
Tutorial 5 Summary..................................................................................................................................... 76
Tutorial 6..................................................................................................................................................... 86
Tutorial 6 Summary..................................................................................................................................... 96
Tutorial 7................................................................................................................................................... 104
Tutorial 7 Summary.................................................................................................................................... 115
Tutorial 8................................................................................................................................................... 126
Tutorial 8 Summary.................................................................................................................................... 136
Tutorial 9................................................................................................................................................... 146
Tutorial 9 Summary.................................................................................................................................... 149
Tutorial 10................................................................................................................................................. 164
Tutorial 10 Summary.................................................................................................................................. 173
Tutorial 11................................................................................................................................................. 181
Tutorial 11 Summary.................................................................................................................................. 188
Tutorial 1
1
,Cognitive failures and accidents – Wagenaar & Hudson
Accidents:
The fire at the detention center Schiphol Airport burned down and resulted in 11
casualties.
Defense mechanisms:
- Alarm code was interpreted incorrect as fire in D wing
- Poor fire safety of the building
- The smoke and heat evacuation installation did not work
Unsafe acts:
- Prisoner who lit the fire in their cell
- The door of the burning cell is left open
Psychological precursors:
Guards were in a state of mind that it was no emergency anymore since false alarms
occurred several times every week. This caused a great seduction not to report the
fire immediately.
General failure types:
- Physical environment
o Missing defenses
o Design failures:
Poor fire safety quality of the building The special walls were
not fire adverting since the fire raged in the whole wing within 14
minutes.
The smoke and heat evacuation installation did not work in the
wing
- Human behavior
o Poor procedures
There was no evacuation plan available for the complex, so that
confusion and panic were enhanced
Door was left open fire and smoke spread to the
hallway
o Defective training
There has never been a calamity exercise for the building and
the personnel
Bad cooperation between guards and fire man
- Management
o Incompatible goals
Reduction of subsidies for the general prison services, even
though the number of prisoners rose. There was a shortage of
2
, personnel mainly private guards instead of well trained and
fixed personnel
Instead of a system that could open all the doors at once, there
was chosen for a system where all doors needed to be openend
by hand. This was according to the minister because the risk of
escape would be too large
The earliest events are faulty management decisions (poor fire safety, installation did
not work, poor procedures and training, incompatible goals). These create latent
errors that remain hidden. But when unsafe acts appear (prisoner who lit the fire), the
accident was caused.
Most efficient way to fight fatal sequences:
- Better fire safety of the building
- Better procedures (evacuation plan)
- Better training (calamity exercises)
- More money for the general prison services, so there can be more well trained
personnel
You have to target the management decisions, so the chain doesn’t even start.
Human error: models and management – Reason
Person approach:
- Focuses on the unsafe acts of people, such as recklessness
- Associated countermeasures are directed at reducing unwanted variability in
human behavior
Unsafe act: Lighting fire in cell by prisoner
Countermeasures: Writing better procedures or disciplinary measures (preventing
that prisoners can light a fire)
System approach:
- Humans are fallible
- Countermeasures are based on the assumption that we cannot change the
human condition, but can change the conditions under which humans work
- Why did the defense fail?
The defense failed because there were a lot of holes (poor fire safety, evacuation
systems did not work, poor training and procedures, incompatible goals).
Countermeasures:
- Better fire safety of the building
- Better procedures (evacuation plan)
- Better training (calamity exercises)
- More money for the general prison services, so there can be more well trained
personnel
3
, Tutorial 1 Summary
Cognitive failures and accidents – Wagenaar & Hudson
The general accident scenario:
- Accidents
o Always caused by unsafe acts. This does not mean accidents are
caused deliberately. In most accidents the actors could not know their
actions would contribute to a disaster.
- Defense mechanisms - Defences
o Guarantee that most unsafe acts do not cause accidents.
o If an accident occurs, this must logically mean that there was a hole in
the defense line
o Strengthening the defenses of a system is the classical engineering
reaction to accidents. The underlying assumption appears to be that
man will always make mistakes, and that a system should be made
‘foolproof’ whenever possible.
o Extra defenses are attractive but will never provide full protection since
it is extremely difficult to anticipate all the foolish things people will do.
o One problem with the amplification of defenses is that there may be
some sort of escalation
“A stronger pressurized vessel, treated the wrong way, will only
produce stronger explosions.”
- Unsafe acts
o Are not random events. They have immediate origins in psychological
states of mind
o Many industrial safety programs are directed towards the reduction of
unsafe acts. Usually such programs attempt to select safe workers and
teach those not to behave unsafely
The underlying assumption is now that people can control their
actions, and that they can avoid unsafe acts, if properly educated
and motivated. There are a few reasons why this assumption is
not always correct:
Not all unsafe acts are violations of any rule, or hazardous
behaviors that are committed in full awareness of their
risks. Unsafe acts lead to accidents only in combination
with other unsafe acts. 48% of the accidents are caused
by a coincidence of unsafe acts committed by 2 or more
people who were not communicating
Many unsafe acts are slips (these are beyond their control
an error in the execution of an otherwise perfect plan.
4
Tutorial 1....................................................................................................................................................... 1
Tutorial 1 Summary....................................................................................................................................... 4
Tutorial 2..................................................................................................................................................... 12
Tutorial 2 Summary..................................................................................................................................... 16
Tutorial 3..................................................................................................................................................... 26
Tutorial 3 Summary..................................................................................................................................... 35
Tutorial 4..................................................................................................................................................... 44
Tutorial 4 Summary..................................................................................................................................... 56
Tutorial 5..................................................................................................................................................... 64
Tutorial 5 Summary..................................................................................................................................... 76
Tutorial 6..................................................................................................................................................... 86
Tutorial 6 Summary..................................................................................................................................... 96
Tutorial 7................................................................................................................................................... 104
Tutorial 7 Summary.................................................................................................................................... 115
Tutorial 8................................................................................................................................................... 126
Tutorial 8 Summary.................................................................................................................................... 136
Tutorial 9................................................................................................................................................... 146
Tutorial 9 Summary.................................................................................................................................... 149
Tutorial 10................................................................................................................................................. 164
Tutorial 10 Summary.................................................................................................................................. 173
Tutorial 11................................................................................................................................................. 181
Tutorial 11 Summary.................................................................................................................................. 188
Tutorial 1
1
,Cognitive failures and accidents – Wagenaar & Hudson
Accidents:
The fire at the detention center Schiphol Airport burned down and resulted in 11
casualties.
Defense mechanisms:
- Alarm code was interpreted incorrect as fire in D wing
- Poor fire safety of the building
- The smoke and heat evacuation installation did not work
Unsafe acts:
- Prisoner who lit the fire in their cell
- The door of the burning cell is left open
Psychological precursors:
Guards were in a state of mind that it was no emergency anymore since false alarms
occurred several times every week. This caused a great seduction not to report the
fire immediately.
General failure types:
- Physical environment
o Missing defenses
o Design failures:
Poor fire safety quality of the building The special walls were
not fire adverting since the fire raged in the whole wing within 14
minutes.
The smoke and heat evacuation installation did not work in the
wing
- Human behavior
o Poor procedures
There was no evacuation plan available for the complex, so that
confusion and panic were enhanced
Door was left open fire and smoke spread to the
hallway
o Defective training
There has never been a calamity exercise for the building and
the personnel
Bad cooperation between guards and fire man
- Management
o Incompatible goals
Reduction of subsidies for the general prison services, even
though the number of prisoners rose. There was a shortage of
2
, personnel mainly private guards instead of well trained and
fixed personnel
Instead of a system that could open all the doors at once, there
was chosen for a system where all doors needed to be openend
by hand. This was according to the minister because the risk of
escape would be too large
The earliest events are faulty management decisions (poor fire safety, installation did
not work, poor procedures and training, incompatible goals). These create latent
errors that remain hidden. But when unsafe acts appear (prisoner who lit the fire), the
accident was caused.
Most efficient way to fight fatal sequences:
- Better fire safety of the building
- Better procedures (evacuation plan)
- Better training (calamity exercises)
- More money for the general prison services, so there can be more well trained
personnel
You have to target the management decisions, so the chain doesn’t even start.
Human error: models and management – Reason
Person approach:
- Focuses on the unsafe acts of people, such as recklessness
- Associated countermeasures are directed at reducing unwanted variability in
human behavior
Unsafe act: Lighting fire in cell by prisoner
Countermeasures: Writing better procedures or disciplinary measures (preventing
that prisoners can light a fire)
System approach:
- Humans are fallible
- Countermeasures are based on the assumption that we cannot change the
human condition, but can change the conditions under which humans work
- Why did the defense fail?
The defense failed because there were a lot of holes (poor fire safety, evacuation
systems did not work, poor training and procedures, incompatible goals).
Countermeasures:
- Better fire safety of the building
- Better procedures (evacuation plan)
- Better training (calamity exercises)
- More money for the general prison services, so there can be more well trained
personnel
3
, Tutorial 1 Summary
Cognitive failures and accidents – Wagenaar & Hudson
The general accident scenario:
- Accidents
o Always caused by unsafe acts. This does not mean accidents are
caused deliberately. In most accidents the actors could not know their
actions would contribute to a disaster.
- Defense mechanisms - Defences
o Guarantee that most unsafe acts do not cause accidents.
o If an accident occurs, this must logically mean that there was a hole in
the defense line
o Strengthening the defenses of a system is the classical engineering
reaction to accidents. The underlying assumption appears to be that
man will always make mistakes, and that a system should be made
‘foolproof’ whenever possible.
o Extra defenses are attractive but will never provide full protection since
it is extremely difficult to anticipate all the foolish things people will do.
o One problem with the amplification of defenses is that there may be
some sort of escalation
“A stronger pressurized vessel, treated the wrong way, will only
produce stronger explosions.”
- Unsafe acts
o Are not random events. They have immediate origins in psychological
states of mind
o Many industrial safety programs are directed towards the reduction of
unsafe acts. Usually such programs attempt to select safe workers and
teach those not to behave unsafely
The underlying assumption is now that people can control their
actions, and that they can avoid unsafe acts, if properly educated
and motivated. There are a few reasons why this assumption is
not always correct:
Not all unsafe acts are violations of any rule, or hazardous
behaviors that are committed in full awareness of their
risks. Unsafe acts lead to accidents only in combination
with other unsafe acts. 48% of the accidents are caused
by a coincidence of unsafe acts committed by 2 or more
people who were not communicating
Many unsafe acts are slips (these are beyond their control
an error in the execution of an otherwise perfect plan.
4
