Andy Brazier - Human factors in risk management

Human Factor Named Biggest Challenge Facing Offshore Oil and Gas [SURVEY]

2012-01-24T11:35:00.002Z

Article at gCaptain 23 January 2012

Survey of industry professionals released today by Oil & Gas IQ.

Found that 48.6% said that human factors and behavioral safety is the biggest challenge regarding offshore safety. Also, nearly three-quarters of survey respondents claimed there was more pressure on offshore operators regarding Health and Safety (HSE) than there had been in previous years, no doubt fueled by recent oil spill disasters such as the Deepwater Horizon spill.

The survey noted that 10.8% of respondents named problems with technology and equipment as a worry, with a similar number saying that having the right processes in place and reacting to new legislation were their firm’s biggest challenges. The study was released ahead of the 2012 Offshore Safety Summit, taking place March 19-21 in Aberdeen

'Human error' blamed for €3.6bn mistake

2011-11-11T08:07:00.001Z

RTE News Ireland 2 November 2011

Minister for Finance Michael Noonan has said the mistake in the national accounts of €3.6bn was down to "human error". He explained in the Dáil that the double count arose because the Housing Finance Agency had borrowed directly from the NTMA instead of from the open market in 2010.

The miscalculation was described as "a humiliating schoolboy error".

Technical Evaluation, Testing and Validation of the Usability of Electronic Health Records

2011-11-04T08:38:00.000Z

Pulished in draft from the National Institute of Standard and Technology September 2011

The report summarises the rationale for Usability Protocol for an Electronic Health Record (EHR) that encompasses procedures for (1) expert evaluation of an EHR user interface from a clinical perspective and a human factors best practices perspective, and (2) validation studies of EHR user interfaces with representative user groups on realistic EHR tasks.

Examples of usability issues that have been reported by health care workers are include:
• Some EHR workflows do not match clinical processes create inefficiencies,
• Poorly designed EHR screens slow down the user and sometimes endanger patients,
• Large numbers of files containing historical patient information are difficult to search, navigate, read efficiently, and identify trends over time,
• Warning and error messages are confusing and often conflicting
• Alert fatigue (both visual and audio) from too many messages leading to users ignoring potentially critical messages, and
• Frustration with what is perceived as excessive EHR user interaction (mouse clicks, cursor movements, keystrokes, etc.) during frequent tasks.

A three step process is proposed for the design and evaluation of EHR as follows:

Step One: During the design of an EHR, the development team incorporates the users, work settings and common workflow into the design. Two major goals for this step that should be documented to facilitate Steps Two and Three are: (a) a list of possible medical errors associated with the system usability, and (b) a working model of the design with the usability that pertains to potential safety risks.

Step Two: The Expert Review/Analysis of the EHR step compares the EHR’s user interface design to scientific design principles and standards, identifies possible risks for error and identifies the impact of the design of the EHR on efficiency. This review/analysis can be conducted by a combination of the vendor’s development team and/or by a dedicated team of clinical safety and usability experts. The goals of this step are: (a) to identify possible safety risks and (b) identify areas for improved efficiency.

Step Three: The Testing with Users Step examines the critical tasks identified in the previous steps with actual users. Performance is examined by recording objective data (measured times such as successful task completion, errors, corrected errors, failures to complete, etc.) and subjective data (what users identify). The goals of this step are to: (a) make sure the critical usability issues that may potentially impact safety are no longer present and (b) make sure there are no critical barriers to decrease efficiency. This is accomplished through vendor-evaluator team review meetings where vendor’s system development and evaluation teams examine and agree that the design has (a) decreased the potential for medical errors to desired levels and (b) increased overall use efficiency due to critical usability issues.

Current training programs may not prepare firefighters to combat stress

2011-11-04T08:17:00.001Z

Medical Xpress 2 November 2011
Article summarises findings from a study by Michael R. Baumann, Carol L. Gohm, and Bryan L. Bonner in an article titled "Phased Training for High-Reliability Occupations: Live-Fire Exercises for Civilian Firefighters,"

The authors assessed the value of current scenario-based training programs and found they may not effectively prepare firefighters for the range of scenarios they are likely to encounter

Firefighters must make complex decisions and predictions and must perform extreme tasks at a moment's notice. Failure to keep a level head in the face of a dangerous situation may result in disastrous consequences. The most common form of training exposes firefighters to one or a very small set of live-fire scenarios designed to reduce stress and encourage calm decision-making skills. But repeated exposure to the same scenario may fail to adequately prepare firefighters for changing situations, as lessons learned in that scenario may not transfer to a different scenario. "If you learn the scenario, you can predict what will happen in that one scenario, but you can't predict what will happen in situations that look a little different," said Baumann. "If you learn general principles, then you can predict what is going to happen in a wide range of situations."

The authors suggest that trainers should increase the range of scenarios to which firefighters are exposed. Desktop-based simulators are available to supplement live-fire training with a variety of scenarios to enable trainees to learn basic principles, even though such simulators cannot replicate a live-fire environment.

The Four Phases of Design Thinking

2011-11-01T08:57:00.000Z

Harvard Business Review blog by Warren Berger 29 July 2011

A good designer has the ability to bring original ideas into the world. They seem to share the same behaviours:

1. Question - Designers ask, and raise, a lot of questions including "stupid questions" that challenge the existing realities and assumptions. Asking "why" can make the questioner seem naïve while putting others on the defensive but it does require people to question and rethink basic fundamentals.

2. Care - Step out of the corporate bubble and actually immerse yourself in the daily lives of people you're trying to serve. Really observing and paying close attention to people. "Focus groups and questionnaires don't cut it."

3. Connect - Taking existing elements or ideas and mashing them together in fresh new ways. You don't necessarily have to invent from scratch but designers know that you must "think laterally" to connect ideas that might not seem to go together.

4. Commit - It's one thing to dream up original ideas. But designers quickly take those ideas beyond the realm of imagination by giving form to them. There is a risk that committing too early increases the possibility of short-term failure but "designers tend to be much more comfortable with this risk than most of us." Innovation is an iterative process and small failures are actually useful because they show the designer what works and what needs fixing.

The Best Approach to Training

2011-10-21T08:34:00.000+01:00

Richard Catrambone's Blog from Harvard Business School 20 October 2011

"One of the ironies of being an expert is that you often lose touch with what it is like to be a novice. Part of becoming an expert is that certain aspects of problem-solving just become automatic......

Experts often are unable to articulate the many "obvious" (to them) things they do when carrying out a procedure or solving a problem." "First, the focus must be on identifying what a learner needs to know."

Task analysis is often used to assess problem solving but they often involve the expert to saying what he/she does without necessarily requiring the expert to justify the steps taken.. An approach taken by Catrambone has been to get experts to go through a problem solving exercise, getting them to talk out loud at every step. He asked them to justify every step as they went through.

"One particularly striking result of this process was how often the instructors had to stop and scratch their heads as they tried to provide a justification for their steps." The notes taken have been used to develop improved training material. "The best way to start to train a novice in any field or to develop good instructional materials is for the expert to actually do the tasks in question. There is just no substitute." But a comment on the blog does call into question the approach: "I believe your premise is flawed from a business application perspective. First there is a difference between teaching and training which you seem to use interchangeably.

The deeper issue however is when you state the fundamental premise of your article, what does the individual need to know? This is not the best question to use as the foundation for "the best approach to training." And quite frankly, because too many corporate (and I would venture a guess - too many academics) training efforts start here is why the training they design suck. The starting and end point must be "what does the individual need to do?" "The best approach to training" is to take accountability for designing learning opportunities that change behavior and ultimately impacts results In a positive way."

Power cut kills Pembroke nursing home man on ventilator

2011-10-20T08:56:00.002+01:00

BBC News 19 October 2011

A power cut during the night killed a man with muscular dystrophy as nursing home staff were unable to connect a back-up power supply, an inquest heard. Gavin Proctor, 35, a resident at the Ashdale home in Pembroke, was on a ventilator to help with his breathing. A jury, which returned a narrative verdict, heard he probably would have lived if an emergency generator or a battery pack was connected.

The power failure happened early on 4 January 2009, cutting off the supply to his ventilator and knocking out all the lights. Senior managers at the home told the jury staff were told regularly how to switch on a back-up generator in an emergency. However the inquest heard even if the generator had been switched on, it would not have saved Mr Proctor's life because it did not provide power to his room. Staff would have had to run extension leads to him in the dark, or use back-up battery packs.

The nurse on duty that night, Helen Corcoran, said she had never connected the battery pack before, which Mr Proctor used for going outside, and was not able to see because the torch she found was not working. Mr Proctor suffered a cardiac arrest and died at the scene.

Peru air crash deaths a 'tragedy of errors' says grieving father

2011-09-29T09:25:00.002+01:00

The Guardian 27 September 2011

The crew and four British passengers died when their Cessna plane came down in a field near the Nazca Lines markings in October 2010. An inquest at High Wycombe law courts heard that all six died instantly when the aircraft hit the ground. The verdict was misadventure Fuel could not reach the engine because a cut-off switch had not been checked. .

The pilot had been drinking, the crew argued and preparations were rushed because the booking was made late in the day and the flight had to be completed before a curfew.

The Fallacy of People Problems and How to Resolve Them

2011-09-07T10:08:00.003+01:00

PharmaPro blog by Jamie Weiss posted 2 September 2011

Statistics in pharmaceutical manufacturing suggest that 80 percent of all reportable deviations are “people problems,” deficiencies of human performance. Despite the pervasiveness of people-caused problems the specific causes attributed are few in number: failure to follow standard operating procedures, skipped or mis-sequenced steps and improper documentation.

But do all of the problems classified as “human factors issues” really indicate a deficiency on the part of a person? Perhaps not. Even classic “people problems,” such as skipping a step in the standard operating procedure (SOP), needs to be examined. This means knowing who the person was, what they did, when it happened etc.. But this requires people to report issues and this can have consequences. Even if they do not fear reprimand, they are likely to be given ownership of the problem and expected to come up with a solution. However, if they keep quiet the chances are production will continue, no one can know and the person does not get landed with the extra work.

When we do look at problems we will sometimes find that people are doing jobs that they are not qualified to do. The test question is: “Could this person do this task if their job or their life, depended on it?” If the answer is yes, then there is no deficiency in the performer. However, for each of us some tasks are simply out of our capabilities and no amount of training would improve our performance.

In this case, retraining is not the option, replacing is. People cannot be expected to do what is impossible for them to learn. Next, consider the response. This asks, “How clear is the desired behaviour that we want from the performer?” “Are we asking for a quantum leap in performance or just a slight tweak?” The response often exposes problems caused by changing the SOP. Perhaps the standards are unclear, the changes too drastic or the expectations unreasonable. If it cannot be changed, training will be required on a constant basis.

The performance system model leaves room for retraining as a corrective action to a people problem, but only when the deficiency is in the performer and even then, only some of the time. Some people are simply not trainable, some skills are not transferable and the optimal solution is rarely “more of the same.” Instead, most corrective actions for performance problems involve addressing the system itself. In short, the solution lies with management to communicate clearly that quality in all its aspects is the priority. This is not done with words and slogans but with rewards, measures ,metrics and behavior. And finally, the solution lies with addressing the common people problem with as much rigor and analytical precision as the most challenging mechanical or biochemical problem.

Tests show fastest way to board passenger planes

2011-08-31T15:32:00.001+01:00

BBC Website 31 August 2011
The most common way of boarding passenger planes is among the least efficient, tests have shown.

Boarding those in window seats first followed by middle and aisle seats results in a 40% gain in efficiency. However, an approach called the Steffen method, alternating rows in the window-middle-aisle strategy, nearly doubles boarding speed. The approach is named after Jason Steffen, an astrophysicist at Fermi National Laboratory in Illinois, US. Dr Steffen first considered the thorny problem of plane boarding in 2008, when he found himself in a long boarding queue. He carried out a number of computer simulations to determine a better method than the typical "rear of the plane forwards" approach, publishing the results in the Journal of Air Transport Management.

The approach avoids a situation in which passengers are struggling to use the same physical space at the same time.

Only now, though, has the idea been put to the test. Jon Hotchkiss, a television producer making a show called This v That, began to consider the same problem of boarding efficiency and came across Dr Steffen's work. Mr Hotchkiss contacted Dr Steffen, offering to test the idea using a mock-up of a 757 aeroplane in Hollywood and 72 luggage-toting volunteers.

The block approach fared worst, with the strict back-to-front approach not much better. Interestingly, a completely random boarding - as practised by several low-cost airlines that have unallocated seating - fared much better, presumably because it randomly avoids space conflicts.

Birmingham hospital error paralysed Newport teenager

2011-08-31T10:41:00.000+01:00

BBC Website 31 August 2011

A teenager was left paralysed from the waist down after a spinal anaesthetic was wrongly left in place for too long, a hospital has admitted.

A pain-killing epidural infusion was not removed for two days after gallstone surgery, permanently damaging her spinal cord. A day after the surgery the patient complained of leg numbness. The following day an MRI scan revealed that the anaesthetic had entered the spinal cord and damaged the membranes, paralysing her from the waist down.

The patient's solicitor called for lessons to be learned. He hoped the staff responsible had already been retrained so that similar "tragedies" could be avoided.

Key Performance Indicators (KPI) for Health and Safety

2011-08-31T08:54:00.001+01:00

Taken from RapidBI website, published November 2007

* Cost of solved safety non-conformances for the month
* Employee perception of management commitment
* Health and safety prevention costs within the month
* Lost time (in hours) due to accidents (including fatalities) per e.g. 100,000 hours worked
* Lost time (in hours) due to non-fatal accidents per e.g. 100,000 hours worked
* Number of fatalities per e.g. 100,000 hours worked
* Number of non-conformance with legal or internal standards in safety inspections
* Number of reportable accidents per e.g. 100,000 hours worked (including fatalities)
* Number of reportable non-fatal accidents per e.g. 100,000 hours worked
* Number of safety inspections for the month
* Number of solved safety non-conformances for the month
* Percentage of attendance at occupational health and safety (OHS) committee meetings
* Percentage of corrective actions closed out within specified time-frame
* Percentage of fatal accidents relative to all accidents (non-fatal and fatal) per e.g. 100,000 hours worked
* Percentage of health and safety representatives (HSR) positions filled.
* Percentage of issues raised by H&S Reps actioned
* Percentage of occupational health and safety (OHS) committee recommendations implemented
* Percentage of products/services assessed for health & safety impacts
* Percentage of significant products and services categories subject to procedures in which health and safety impacts of products and services are assessed for improvement
* Percentage of staff with adequate occupational health and safety (OHS) training
* Total of hours in safety and health training in the month

Why should businesses invest in ergonomics?

2011-08-29T18:10:00.001+01:00

Central Wisconsin Business 22 August 2011 - the Raikowski column

Statistics from the article:

* The Occupational Health and Safety Administration indicates that MSDs account for one-third of the 1.7 million occupational injuries and illnesses in the U.S. every year and represents its largest work-related injury and illness issue
* Including workers' compensation costs and factors such as restricted duty time, reduced worker productivity, and diminished work product and quality, OSHA estimates that MSDs annually cost the U.S. workforce $54 billion.
* The National Institute for Occupational Safety and Health reviewed hundreds of scientific studies. The estimated cost savings associated with averting a single musculoskeletal disorder-related workers' compensation claim is a whopping $22,546. This total includes the value of lost production, medical costs, insurance administrative costs, and indirect costs to employers.

The FOH cites examples of employers reporting positive returns on their ergonomics program investments including:

* Between 1992 and 1996, the New York Times reported that it reduced its workers' compensation claims by 84 percent, reduced lost work time by 75 percent and decreased lost workdays by 91 percent as a result of its ergonomics program.
* Intracorp reported that a public service company with 330 employees realized a return of $7.35 for every $1 invested in its ergonomics program.
* Northwest Aerospace Company realized a 10- to 15-percent increase in productivity (a benefit of greater than $200,000) following implementation of an ergonomics program.
* Jerome Foods Inc. reported saving $3 for every $1 invested in an ergonomics program.

Air traffic overhaul hinges on 'human factor'

2011-08-18T11:47:00.001+01:00

CNN Website on 10 March 2011 by Thom Patterson

"Even amid the amazing technological achievements and wondrous capabilities of the 21st century, the most critical connection in the airline industry remains the same as it was at the birth of aviation: the human touch."

According to the article the role of the human factors engineer "is to ensure that information is being presented at the right time to a pilot and in the right form so that the human cognitive capabilities are not simply overwhelmed." In particular "What should you put in front of a pilot and in what form should that information be?"

Referring to new air traffic control technology called Automatic Dependent Surveillance-Broadcast (ADS-B) that allows pilots to see a real-time cockpit display that shows the locations of their aircraft and any surrounding aircraft. The challenge is to keep the human in the loop. The plan calls for pilots and air traffic controllers to share more information -- allowing them to better collaborate in avoiding mistakes. They have proven that the human remains in charge and pulls the whole system together, but it requires a rethink in the way information is processed and used.

Another system being developed is a very sophisticated kind of "text message." The aim is to cut confusion caused by misunderstood voice radio transmissions and to improve efficiency by "texting" routine information. Obviously, it is important to make sure this doesn't cause distraction. A lot of messages will be pre-programmed and sent by pilots with the touch of a single button.

$10 piece of equipment could’ve saved $128K in compensation benefits

2011-08-15T08:43:00.002+01:00

HR Morning 11 August 2011 by Christian Schappel

The brief article illustrates the potential financial benefits of applying ergonomics. I would add that the employee in question also suffered significant physical harm.

"Angela Grott, a finance clerk at the Menard Correctional Center in Illinois had requested a headset for her phone. The reason: She often had to type while speaking on the phone. Her request was denied, and she carried on with her work — holding her phone receiver in the crook of her neck for hours at a time while typing."

Grott started to suffer from severe neck, shoulder and arm pain and headaches. She underwent surgery in an attempt to relieve her pain. The medical bills came to $128,424 for medical bills and Grott received $7,304 for 12 weeks of temporary disability pay. She may even be able to claim a permanent partial disability claim, which be more than $100,000.

And a headset would have cost about $10.

Smart Keys: Not So Smart for Motorcycles?

2011-08-05T08:46:00.001+01:00

Wall Street Journal 30 April 2011 by Jonathan Welsh
"Imagine beginning a ride only to find that you cannot steer.That’s what could happen with certain Ducati motorcycles because of a potential problem with their electronic steering locks, which are part of their anti-theft systems."

The bikes affected are the latest models that come with an electronic ‘smart key” that allows the rider when carrying the key (i.e. in their pocket) to get on the bike, start it and ride away without having to actually handle the key. However, during testing it was found that “under very specific conditions” the electronic steering lock could fail to disengage automatically during the process of turning on the bike’s ignition on and starting the engine. If this happens a rider could potentially start the bike and begin riding while the steering is still locked – an obvious hazard!.

Ducati are recalling the bikes.

CF-18 Hornet crash focuses on human factors

2011-07-29T11:21:00.006+01:00

Bonnyville Nouvelle 28 July 2011

Preliminary report into a crash of a CF-18 Hornet crash has found the aircraft was operating normally and focuses on human factors. It was undergoing two-aircraft formation night vision goggles training mission, The pilot ejected and was unharmed.

The report states that as the pilot selected the landing gear, a sudden rush of falling snow, illuminated by his landing light, disoriented him. It reflected through his head up display and washed out the instrument references used to control the aircraft. He thought he was going to crash, could not tell if his avoidance actions were working so ejected.

The pilot was inexperienced at night flying and had not undergone a night vision goggles mission in 224 days. Direction has been given for night vision goggles training to now start “only after a pilot has increased flying experience.”

The investigation continues.

Poland finds Russia at fault for presidential jet crash

2011-07-29T11:14:00.001+01:00

BBC Website 28 July 2011

Human factors in motor racing

2011-07-14T15:56:00.000+01:00

Article in the Washington Post on 13 July 2011

An interesting view of human factors vs technology in Formula 1 and Nascar racing.

It suggests the human factor is being taken out of Formula 1 because so much data is streamed back to technicians in the pits. However, Nascar does not allow this in order to "highlight the human element in racing" and "to make the events more interesting to the consumer."

The implication is that technology means human factors are less relevant in Formula 1 than Nascar. I can see what they are getting at, but not sure I agree with their conclusion. I would suggest that human factors in Nascar is limited to one person (the driver) whereas in Formula 1 it is far more of a team effort, which means different and more complex human factors are involved.

Apparently Williams F1 has worked with AT&T to increase the speed at which data gets transmitted, which is now 25 times faster than a standard broadband setup. "The technology has helped cut down on the number of support staff traveling with F1 teams, as well as the cost."

Spelling mistakes 'cost millions' in lost online sales

2011-07-14T07:35:00.000+01:00

BBC Website by Sean Coughlan 14 July 2011

Online entrepreneur Charles Duncombe says that poor spelling is costing the UK millions of pounds in lost revenue and that a single spelling mistake can cut online sales in half.

He says he measured the revenue per visitor to the tightsplease.co.uk website and found that the revenue was twice as high after an error was corrected.

"If you project this across the whole of internet retail then millions of pounds worth of business is probably being lost each week due to simple spelling mistakes," says Mr Duncombe, director of the Just Say Please group.

Spelling is important to the credibility of a website, he says. When there are underlying concerns about fraud and safety, then getting the basics right is essential.

When a consumer might be wary of spam or phishing efforts, a misspelt word could be a killer issue”

William Dutton Oxford Internet Institute

"You get about six seconds to capture the attention on a website."

Spelling and grammar are not so important on informal parts of the internet, such as Facebook. However, home pages or commercial offerings that are not among friends and mistakes raise concerns over trust and credibility.

Figures from the Office for National Statistics published last month showed internet sales in the UK running at £527m per week.

Ineos fined over Grangemouth refinery oil spill

2011-07-12T13:34:00.001+01:00

BBC Website 5 July 2011

The owners of Grangemouth refinery have been fined £100,000 over a spill of highly flammable oil. In the incident, a pipeline became pressurised and sprayed crude oil across a nearby pumphouse and pipelines containing other dangerous liquids.

An investigation found the company had been aware of the risk and the need to install controls.

But it also found Ineos chose to rely on staff to reduce pressure by manually draining oil from the pipeline, and storing it in a skip that was not designed for storing oil.

Further information from SHP magazine 8 July 2011

An incident occurred in May 2007 that resulted in more than 100 litres of crude oil being released on to the floor of a pumphouse. The HSE advised the company to install a hydrostatic release valve, which would divert some of the oil to a storage container once it reached a certain pressure.

However, INEOS failed to act on this suggestion, and it continued to be common practice to allow pressure to build up in the pipes until a warning alarm sounded in the control room when the pressure reached 19 bar. The controller would then instruct a field operative to drain oil from the pipeline to release the pressure.

On 7 May 2008, following a shift change in the control room, staff became confused by the method of work. When the pressure alarm sounded, the controller was unaware that the method of work required him to arrange for the pressure to be released manually. Four hours after the alarm sounded a gasket on the pipeline ruptured and oil began spraying across a nearby pumphouse and adjacent pipelines containing other dangerous substances. Nobody was injured during the leak but it posed a serious risk of causing a fire, or explosion.

According to HSE "Despite having recognised the need for engineered thermal relief on their crude-oil pipelines, following an incident at their refinery a year earlier, INEOS chose instead to rely on a manual system for managing thermal expansion. This system of work actually increased the risk of fire and explosion and ultimately failed to prevent the pipeline from becoming over-pressurised. The risk of over-pressurising pipelines and storage vessels, as a result of thermal expansion, are well-understood, as are the required control measures."

Society has to learn to abhor distracted driving.

2011-07-08T08:23:00.000+01:00

NTSB investigation findings 7 July 2011 By Deborah Hersman

The NTSB has determined that a 2010 accident in the Delaware River involving a barge towed by the tugboat Caribbean Sea and killed two Hungarian tourists was caused by the tugboat mate’s failure to maintain a proper lookout due to his repeated use of a cellphone and a laptop computer.

"What’s scary is that no one on board the tugboat objected to the mate’s blatant violation of company policy in making 13 calls and receiving five during the 80 minutes preceding the accident. None of the crew members reported his repeated use of his personal cellphone."

The NTSB has found such use of personal electronic devices to be widespread across all modes of transportation. They included:

* October 2009 - Two airline pilots were out of radio communication with air traffic control for more than an hour because they were distracted by their personal laptops resulting in them overflying their destination by more than 100 miles.
* September 2008 - A commuter train running a red signal in suburban Los Angeles in September 2008 killing 25 and injuring dozens. The engineer, had sent and received 250 text messages during the three days leading up to the accident.
* The driver of a tractor-trailer made 97 calls and received 26 during the 24 hours preceding an accident. And in the half-hour prior to the crash, the driver spent 14 minutes — nearly half his time — on the phone. Ten people died that day after the truck crossed a median.

"Despite company policies, public education campaigns, and, in some places, laws designed to minimize driver distraction, many people continue to engage in unsafe and unacceptable behavior, thinking." "We have to change public tolerance for such distractions and elevate society’s disapproval of the use of personal electronic devices while operating a vehicle."

In 1967, the NTSB investigated the midair collision of a Piedmont Airlines Boeing 727 and a private twin-engine aircraft, which killed all 82 people aboard both planes. The original investigation showed that shortly after takeoff, crew members aboard the 727 discussed a fire in a cockpit ashtray and joked among themselves as they put it out. At the time, cigarette smoking and burning cockpit ashtrays were so common that the NTSB did not even mention the “detail” in the final report.

Today, of course, we can’t imagine smoking in an airplane, much less the cockpit, without anyone’s taking notice. So what has changed since 1967? Cultural and societal expectations. Smoking on airplanes is not only not allowed; it’s not even remotely considered.

Congress first banned smoking on planes in 1988. That law, which applied to flights of two hours or less, took two decades of pressure from health and consumer organizations, as well as repeated warnings about the dangers of secondhand smoke by the National Academy of Sciences and the surgeon general. Today, more than two decades after that initial legislation, society’s disapproval of smoking on airplanes — and in many other public places — is pervasive.

We have to reach the point where texting, phoning, and engaging in other distracting behaviors while operating a vessel, train, or motor vehicle are just as unacceptable as smoking on an airplane. How many more lives will we lose before we correct our tacit and deadly acceptance of distraction?

Electoral Commission sorry for out-of-date AMs advice

2011-07-05T16:19:00.000+01:00

BBC news 5 July 2011

The elections watchdog has apologised after a new Welsh assembly member fell victim to out-of-date guidance for candidates and was disqualified.

An independent investigation found Liberal Democrat Aled Roberts did everything reasonably expected.

The relevant guidance was changed before the election, but only the English language document was updated. The AM only referred to the Welsh language version, which was out of date.

Why? How? Prove it

2011-07-04T14:57:00.000+01:00

Just googling around looking at tips to improve my presentation skills. Came across www.whyhowproveit.co.uk

The suggestion is a four stage approach.

1. Key Message - Leave your audience in absolutely no doubt what you came to tell them in a succinct way

2. Explain to your audience "why should I do that?"

3. Explain how they can do it (this is examples, and actually the least important part of the presentation)

4. Use personal examples, case studies and statistics to prove you are talking sense.

WHPI - seems like a good way of focussing the mind when preparing.

Homicide verdict for CEO after health and safety cuts

2011-06-29T08:19:00.000+01:00

International Law Office website 27 June 2011

An Italian court has sentenced the chief executive officer (CEO) of a company to 16 years' imprisonment for an offence related to the deaths of seven employees. This is the first such case in Italy in which a CEO has been found guilty of homicide, rather than manslaughter. The court found the company liable under Law 231/2001 and ordered it to pay a fine of €1 million. In addition, it confiscated a further €800,000 and banned the company from receiving public funds for six months.

The case concerned an incident at a factory operated by the company ThyssenKrupp. On the night of December 6 2007 a fire broke out on the production line and could not be extinguished because of a lack of fire extinguishers and the absence of other safety features. Seven workers were killed.

At trial, the prosecutor claimed that ThyssenKrupp's senior management had decided not to invest in health and safety at the factory, since they had decided to relocate production to another site. Therefore, the management knew that it was accepting a risk that a serious accident could occur and was aware of the potential legal consequences of the decision.

The prosecutor argued that if a senior manager decides to reduce investment in health and safety, he or she is aware that there is a high probability of a serious accident. If an accident occurs and someone dies as a result, the manager in question must be deemed guilty of homicide. Although the grounds have not yet been published, the decision indicates that the court appears to have agreed with this argument.