The Weight of a Decision

Hello All,

The Weight of a Decision

In the book The Twenty Four Hours Society by Martin Moore-Ede, M.D., Ph.D., Moore-Ede writes about the enormous power some corporate employees have in the decision making process in the execution of their job. With more power comes more risk. Some decisions can produce tragic outcomes as we witnessed in the nuclear, chemical, space/aviation, and oil industries of past events.

Dr. Moore-Ede writes, "such risk gives today's chief executive nightmares. An error by a junior person earning one-hundredth of a CEO's salary and whom the CEO has never met can bankrupt the company and deprive all employees their job”. One CEO of Unocal, recently circulated a videotape to his employees urging extreme care in safety-sensitive operations such as shipping or trucking oil, because it would take only one such major accident to bankrupt his company.

Recent case in point is the Viking Sky cruise ship that had to be evacuated off the coast of Norway last weekend, Low oil levels led to ship engines shutting down. Investigators believe heavy seas near Hustadvika probable caused movements in the oil tanks so large that the supply to the lubricating oil pumps stopped. This triggered an alarm indicating a low level of lubricating oil, which in turn shortly thereafter caused an automatic shutdown of the engines.

Who made the decision to set sail with marginal oil filled tanks?

www.system-safety .com has produced a video (click on “Safety Videos”) based on an actual accident to a DC8 in Jeddah, Saudi Arabia. One of the primary causes was the maintenance error in judgment that lead to the fatal accident that took the lives two hundred and sixty-one people. This airline also did not survive this horrific event.

Is there any decision making process that you need to revisit in the execution of your duties that will further reduce the possibility of an incident or accident?

Click here for issue 07

Be Safe in the Region of Risk

Roger Hughes

Decoding Human Factors, LLC

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