COLLEGE 1 BLOK CRISISBEHEERSING ........................................................................................... 5
Waar is de overheid mee bezig? Links ...........................................................................................5
CRISIS ..............................................................................................................................................5
Manier van samenwerken ............................................................................................................5
BEDRIJVEN KANT- RECHTS ......................................................................................................................6
Waar kijken bedrijven naar? .........................................................................................................6
Wat hebben ze bedacht om de bedrijf continuïteit te organiseren? .................................................6
VEILIGHEIDSKETEN ...............................................................................................................................7
Risicobeheersing .........................................................................................................................7
Crisisbeheersing .........................................................................................................................7
3 NIVEAUS VAN HET IN KAART BRENGEN VAN RISICO’S DOOR DE OVERHEID ..........................................................8
NOODPLANNING .................................................................................................................................8
Standaard voor noodplanning NEN8112 .......................................................................................8
HOOFDSTUK 1 SONJA JANICIJEVIC............................................................................................................9
Risicomanagement, waarom? ......................................................................................................9
Piramide van Maslow ..................................................................................................................9
Vuca-wereld .............................................................................................................................. 10
Definitie risico ........................................................................................................................... 11
HOOFDSTUK 2 SONJA JANICIJEVIC.......................................................................................................... 11
Soorten risico’s ......................................................................................................................... 11
HOOFDSTUK 3 SONJA JANICIJEVIC.......................................................................................................... 12
Wat is een systeem? .................................................................................................................. 12
ISO ........................................................................................................................................... 12
COSO ....................................................................................................................................... 12
Wat zijn systemen? .................................................................................................................... 12
HOOFDSTUK 4 SONJA JANICIJEVIC.......................................................................................................... 13
Risicomanagementproces volgens ISO3100 ............................................................................... 13
HOOFDSTUK 5 SONJA JANICIJEVIC.......................................................................................................... 13
Risico identificatie ..................................................................................................................... 13
HOOFDSTUK 6 SONJA JANICIJEVIC.......................................................................................................... 14
Risicobeoordeling...................................................................................................................... 14
Met de uitkomsten kun je 2 dingen doen:..................................................................................... 14
HOOFDSTUK 7+8 RISICOBEHEERSING SONJA JANICIJEVIC ............................................................................ 14
ALARP ....................................................................................................................................... 14
COLLEGE 2 ONGEVALSANALYSE ..................................................................................................15
Bow-Tie..................................................................................................................................... 15
Definitie: Prospectief onderzoek .............................................................................................. 15
Prospectief onderzoek: .............................................................................................................. 16
Definitie: Retrospectief onderzoek........................................................................................... 16
VERKLARENDE THEORIEËN 2DE DEEL VAN HET COLLEGE ...............................................................17
DE GRONDLEGGERS ONGEVALSTHEORIE ................................................................................................ 18
Definitie Causaliteit: .................................................................................................................. 18
Definitie determinisme: .............................................................................................................. 18
DOMINO MODEL HEINRICH SAFETY-LEER ............................................................................................. 19
Hoe moet je het model zien? ...................................................................................................... 19
Het denken van Heinrich ............................................................................................................ 20
Definitie: Monocausaal verband ................................................................................................. 20
PIRAMIDE VAN HEINRICH SAFETY-LEER .................................................................................................. 20
PCDA-CYCLUS DEMING JAREN 50 KWALITEITSLEER ................................................................................... 21
BROKKENMAKERS THEORIE JAREN 50 SAFETY-LEER .................................................................................... 21
, REGEL VAN PARETO SAFETY-LEER .......................................................................................................... 22
MENSELIJK FALEN REASON JAREN 70 SAFETY-LEER................................................................................... 23
Onbedoelde handelingen: .......................................................................................................... 23
Bedoelde handelingen: .............................................................................................................. 23
NIEUWE INLICHTING REASON JAREN 90 ................................................................................................... 23
AANGEPAST DOMINO-MODEL (HEINRICH) DOOR REASON JAREN 90 ............................................................... 24
Uitleg van het aangepaste model van Reason: ............................................................................ 24
Directe vs. Basisfaalfactoren ...................................................................................................... 25
HOORCOLLEGE 2 DEEL 2, MODELLEREN VAN ONGEVALLEN (4 MODELLEN) ...................................26
MODEL 1→S137 .............................................................................................................................. 26
Wat is een S137? ....................................................................................................................... 26
Het proces en de structuur van S137 .......................................................................................... 26
FOUTENBOOM .................................................................................................................................. 28
DE FOUTENBOOM (FTA)...................................................................................................................... 28
RCA .............................................................................................................................................. 30
GATENKAASMODEL REASON................................................................................................................. 32
TROPOD-BETA .................................................................................................................................. 34
PRISMA MODEL ................................................................................................................................. 37
COLLEGE 3 HUMAN & ORANIZATION FAILURE ...............................................................................39
HUMAN FAILURE 1 ............................................................................................................................ 39
Human Failure Normal 1981 ...................................................................................................... 39
HUMAN FAILURE 2 ............................................................................................................................ 40
Human Failure (Rasmussen 1983) ............................................................................................. 40
HUMAN FAILURE 3 ............................................................................................................................ 41
Human Failure Reason 1990 ...................................................................................................... 41
ORGANISATIE FALEN .......................................................................................................................... 42
Latente Failure (Latent Fouten) ................................................................................................. 42
Active Failure (Actieve Fouten) .................................................................................................. 42
ORGANISATIE FALEN .......................................................................................................................... 43
Incubatie theorie (Turner 1978-1997) ......................................................................................... 43
ORGANISATIE FALEN .......................................................................................................................... 44
Normalization of deviance (Voughan 1996) ................................................................................. 44
ORGANISATIE FALEN .......................................................................................................................... 47
Partical Drift theorie (Snoook 1996) ............................................................................................ 47
ORGANISATIE FALEN .......................................................................................................................... 47
Drift to Danger (Rasmussen 1997) .............................................................................................. 47
COLLEGE 4 ORGANISATIE EN SYSTEEM FAILURE ...........................................................................49
VOORBODES SYSTEM FAILURE ............................................................................................................... 49
COMPLEX SYSTEEM ........................................................................................................................... 49
Three Mile Island 28 maart 1979 Harrisburg ................................................................................ 49
Normal Accident theory (Perrow 1984 en 2010) NAT ................................................................... 50
ANTWOORD OP NORMAL ACCIDENT THEORIE (1995-2020) ......................................................................... 52
1ste antwoord Resillience Engineering (Hollnagel & Woods 2006) ................................................ 52
2de antwoord Zero Vision (Duncan 2012) .................................................................................... 52
3de antwoord High Reliability Organization HRO (Dekker, 2014,2017-Weick & Sutcliffe 2014) ...... 53
COLLEGE 5 SAFETY I – SAFETY II ...................................................................................................54
PROGRAMMA HC 5 ......................................................................................................................54
VERBETEREN VAN PREVENTIVE ............................................................................................................. 55
Zero Vision Model (Colin Duncan, 2012) ..................................................................................... 55
WERKEN AAN CULTUUR ...................................................................................................................... 56
Veiligheidscultuurladder (Parker & Hudson) ............................................................................... 56
WERKEN AAN CULTUUR ...................................................................................................................... 57
, Managing the unexpected (Weick & Sutcliffe 2015) .................................................................... 57
WERKEN AAN CULTUUR ...................................................................................................................... 58
Safety I & Safety II (Erik Hollnagel 2014) ..................................................................................... 58
WERKEN AAN CULTUUR ...................................................................................................................... 60
Crew Resource management ..................................................................................................... 60
Belangrijke aspecten voor een succesvol Crew resource management:........................................ 60
WERKEN AAN CULTUUR ...................................................................................................................... 61
Resilience engineering (O.A. Hollnagel) ..................................................................................... 61
WERKEN AAN CULTUUR ...................................................................................................................... 61
Risicoleiderschap (Van Staveren) .............................................................................................. 61
WERKEN AAN CULTUUR ...................................................................................................................... 62
Nieuwe rol voor veiligheidskundige ............................................................................................. 62
COLLEGE 6 MANAGEMENTSYSTEMEN ..........................................................................................63
WAT IS EEN MANAGEMENTSYSTEEM? DILLEN H1,2 ..................................................................................... 63
ONTWIKKELING IN MANAGEMENTSYSTEMEN ............................................................................................. 63
BELANGRIJKE STANDAARDEN VOOR ONS: ................................................................................................. 64
WAT IS ISO EN WAT IS NEN? ................................................................................................................ 65
ISO (International Organization for Standardization) ................................................................ 65
NEN (Nederlandse Norm) ......................................................................................................... 65
HIGH LEVEL STRUCTURE: INDELING VAN DE NORMEN DILLEN H1.3 ................................................................ 65
Belangrijke punten over de High Level Structure: ......................................................................... 66
Samenhang in structuur HLS .................................................................................................... 67
WELKE NORM/RICHTLIJN IS VAN TOEPASSING VOOR MIJN BEDRIJF? .................................................................. 68
OPBOUW VAN VMS ........................................................................................................................... 68
OPBOUW VAN ISO 45001 ................................................................................................................... 69
UITGANGSPUNTEN VMS DILLEN H1.4: IN SPECIFIEK ISO 45001................................................................... 69
1. De PDCA- Cirkel..................................................................................................................... 69
2. Procesbenadering Dillen H1.4.2.............................................................................................. 71
3. Risicobenadering> op 2 niveaus .............................................................................................. 73
4. Context- en stakholdersbenadering ........................................................................................ 74
CONTEXTANALYSE H4 DILLEN............................................................................................................... 75
De contextanalyse ..................................................................................................................... 75
Interne/externe belanghebbende................................................................................................ 76
Instrumenten voor contextanalyse .......................................................................................... 77
COLLEGE 7 ..................................................................................................................................79
ONTWIKKELING (R-VH-) MANAGEMENT SYSTEMEN ...................................................................................... 79
Wat zijn BRZO bedrijven? ........................................................................................................... 79
NTA 8620 .................................................................................................................................. 79
ONTWIKKELTIJD NEN, NTA EN ISO........................................................................................................ 80
NEN-normen (Nederlandse normen) .......................................................................................... 80
NTA (Nederlandse Technische Afspraak) .................................................................................... 80
ISO-normen (Internationale normen) .......................................................................................... 80
LEIDERSCHAP DILLEN H5 .................................................................................................................... 81
TOP VAN EEN BEDRIJF.......................................................................................................................... 81
Leiderschap .............................................................................................................................. 81
Management ............................................................................................................................. 81
LEIDERSCHAP STANDAARDEN................................................................................................................ 82
WAAR ZIT LEIDERSCHAP IN?.................................................................................................................. 83
PDCA-cirkel (Deming cirkel) ....................................................................................................... 83
Procesbenadering ..................................................................................................................... 83
Risicobenadering....................................................................................................................... 83
Context- en stakeholderbenadering ............................................................................................ 83
PLANNING DILLEN H6 ........................................................................................................................ 83
UITVOERING DILLEN H8 ...................................................................................................................... 84
A) beheersing (hygiëne strategie) ................................................................................................ 84
, B) omgaan met verandering (MoC) .............................................................................................. 84
C) Noodplanning ....................................................................................................................... 85
D) Inkoop .................................................................................................................................. 86
E) Ondersteuning en vastlegging (Dillen H7) ................................................................................ 86
INHOUD VAN EEN VEILIGHEIDSMANAGEMENTSYSTEEM ................................................................................. 86
COLLEGE 8 DILLEN H9 + 10 ...........................................................................................................88
EVALUATIE VAN DE PRESTATIES DILLEN H9 ............................................................................................... 88
VERBETERING H10 ............................................................................................................................ 88
MONITORING EN METING DILLEN HOOFDSTUK 9 ........................................................................................ 88
Wat zegt de norm (Dillen H9.1.1 van ISO45001) ........................................................................... 88
Meten is weten .......................................................................................................................... 89
Wat hoort hier nog meer bij? ....................................................................................................... 89
INTERNE AUDIT DILLEN HOOFDSTUK 9.2 .................................................................................................. 89
Definitie uit ISO 19011................................................................................................................ 89
Typen audit ............................................................................................................................... 90
Auditplan .................................................................................................................................. 91
Hoe ga je zo’n audit doen? ......................................................................................................... 91
Wat leveren ‘’interne audits’’ nou op? ......................................................................................... 91
Directiebeoordeling Dillen Hoofstuk 9.3 ...................................................................................... 91
Management review/ Directiebeoordeling ................................................................................... 92
VERBETERING DILLEN HOOFDSTUK 10 .................................................................................................... 93
Verbetering ............................................................................................................................... 93
1. Cultuurtypologie van Harrison................................................................................................ 94
2. Het lagenmodel van Hofstede (Ui-model................................................................................ 95
3. Deal en Kennedy: Cultuur is contextafhankelijk ...................................................................... 96