MENSEN EN CALAMITEITEN van de Sande in lezingen by liaoqinmei


									TEVAPHARMA Haarlem   14 september 2010
      Two kinds of safety hazards

Loss of life,
health or
material losses
in modern
                        Some chemical disasters
June 1, 1974:
Flixborough disaster, England. An explosion at a chemical plant near the village of Flixborough kills 28 people and seriously
injures another 36.
July 10, 1976
Seveso disaster, in Seveso, Italy, in a small chemical manufacturing plant of ICMESA. Due to the release of dioxins into the
atmosphere and throughout a large section of the Lombard Plain, 3,000 pets and farm animals died and, later, 70,000 animals
were slaughtered to prevent dioxins from entering the food chain. In addition, 193 people in the affected areas suffered from
chloracne and other symptoms. The disaster lead to the Seveso Directive, which was issued by the European Community and
imposed much harsher industrial regulations.
December 3, 1984:
TheBhopal disaster in India is the largest industrial disaster on record. A faulty tank containing poisonous methyl isocyanate
leaked at a Union Carbide plant. About 20,000 people died and about 570,000 suffered bodily damage.[1] The disaster
caused the region's human and animal populations severe health problems to the present
November 1, 1986:
The Sandoz disaster in Schweizerhalle, Switzerland, releasing tons of toxic agrochemicals into the Rhine.
June 28, 1988:
Auburn, Indiana, improper mixing of chemicals kills four workers at a local metal-plating plant in the worst confined-space
industrial accident in U.S. history; a fifth victim died two days later.[2]
October 23, 1989:
Phillips Disaster. Explosion and fire killed 23 and injured 314 in Pasadena, Texas. Registered 3.5 on the Richter scal
September 21, 2001:
Toulouse, France. An explosion at the AZF fertilizer factory killed 29 and injured 2,500. Extensive structural damage to
nearby neighbourhoods..
                 LIFE as A STRUGGLE
• Typical for life is that it answers to a fundamental law,
  known as Murphy’s law
• So we try to develop systems in which nothing can go wrong
• We normally do that by creating big, intricate and well designed
  systems, by striving to be in control, to be prepared
• This only works for a limited time: until Murphy strikes again
• A simple solution would be not to expect anything, and to have no goals nor policies
• A solution halfway the Normal and the Zen solution would be to
  optimise the capacity to react to failures: Flexibility, Resilience
• Resilience is the degree in which a system is able to deliver an
  acceptable service level during unexpected happenings like
                             see Karl Weick
• “Organisation” is a word for something that is not a thing
• An organisation does not exist as such, it is a set of appointments
  that makes happenings predictable
• Humans like predictability: Therefore they make appointments,
  therefore they organise
• When something unexpected happens, we experiment with
  different solutions: improvisation
• When a solution has some promise, we promote it to a procedure
• When we have several procedures, we try to integrate them in a
• When we have procedures and structures we give it the proud name of
• But remember: When the unexpected happens, we always have to
  begin with improvisation
• Accidents and crises are always unexpected
                    Weick’s model

The Unexpected

                    Improvisation      Procedures      Structures
                     (Enactment)       (Selection)     (Retention)

  The more we progress from Enactment to Retention, the better we
  think our organisation is. But it isn’t. This is the reason why
  organisations strive to control their environment
                        The morale
• The morale of this analysis is that organisations are designed to
  function in a stable, predictable environment
• When the unexpected happens we must fall back on
• People are not used and trained to improvise, they are used and
  trained to think inside the box…..
• Because in a well designed organisation everything is taken care
  of and humans, as habit forming animals, easily adapt to that

• A solution may be to make the boxes so small that they just have
  to think outside them, but how can that be done?
• Maybe autonomous groups are the answer
    Two kinds of safety hazards

Loss of
or capital
                   The aftermath
• Once the incident is over, your problems
• Many parties will seek redress:
  – Victims from outside, aided bij lawyers
  – Victims from inside, also with some help
  – The state and its organs will try to help itself
• It would be good to prepare yourself for such
  an onslaught
• I will give you some simple guidelines
 How strongly will the shit hit the fan?

       Psf = BRM²
Psf=   Power with which shit will hit fan
B=     Blameability of VIP or organisation
R=     Relevance (relative to other factors)
M=     Mediagenicity
Sue'em... lawsuits and information on suing chemical
 Parents are angry about toxic products that don't work and
           are taking the chemical companies to court.
   • As a public service, we will post each lawsuit on our
                        • Class Action Lawsuit:
   • The Texas Class Action Lawsuit filed 2001 - Head Lice Products
             • Click here to read lawsuit and get involved
                • Have you been injured by Chlordane?
                  • Seeking justice for the poisoned?
                               • Click Here
                     • If you were injured by Dursban,
               • You may want to look into this class action:
              • The California Class Action Lawsuit (4/99)
        • FTC (Federal Trade Commission) 9/18/98 findings.
                  • The Virginia Class Action Lawsuit
                    • click here to see what happened
                       • Terminix - Taken to Court
How to cope with Blameability
            How to cope with Relevance
Some general remarks

1. Pray
2. Switch to a field that is less relevant
   than pharmacology
3. Act before their lawyers get in
4. Sit still when you’re being shaved
5. Remember that for most journalists
   relevance lasts three days
       How to cope with the Media

• Take care that no ‘iconic’ videos or
  pictures can be taken
• Never get chummy with media people
• Try to cooperate with media people
  – Advice: Look at the situation from their side
• If you hire a PR agent, do it before
  anything has happened
  – It’s cheaper and more effective
               Part III
Can we forestall these nasty
situations called accidents?
                          Yes!!! But for
                           that you must
                          analyse human
• It is to be expected that accidents will happen
• Prevention is very important but not sufficient
• There must also be repression
• People who work at repressing the consequences of
  accidents obey, just as you do, to psychological laws
• An important class of these laws concerns acting
  under uncertainty
• We will see what training can do in this respect
• Fimally we will look at distraction
    Acting when the situation is uncertain
• Uncertainty fosters a physio/psychological state called
  arousal, a state of heightened alertness
• Evolutionary seen this state is very old: reptiles and insects
  also get aroused in case of danger or opportunity
• Typical symptoms:
   – Funnelvision (only attend to those factors of which you are uncertain),
   – Insensitivity to punishment and pain (which consequently do not play a role in
     decision making)
   – Decisions more than usual are taken on the basis of habits and emotions
     (normally this is already strong enough)
   – Tendency towards polarization: Black or White, Right or Wrong
   – Uncertainty leads to constant endeavours to solve it by simple intuitive
     arguments. Consequently there is less capacity for more sophisticated
     argumentation (peripheral in stead of central information processing)
• We try to counter the effects of arousal by training
• In the best case training causes
    – a. Less equivocality and uncertainty (and so less funnelvision and insensitivity for pain and
    – b. Opportunity to experience unusual emotions and thus an experience in coping with them
    – c. A more intense experience of qualities and personalities of coworkers. Generally this heightens
    – d. Evaluating of and ruminating on what happened during the training, promotes the construction of
      arguments and argumentation that helps in a rational approach of the unexpected
• Training remains a poor substitute for experience, however realistic the
  training is made, but we have nothing better
• Typical for most training procedures is that they mainly aim at our rational
  side, but that they hardly have any effect on the very important emotional
  aspects of accidents and disasters
• A negative effect of good training may be that it promotes false self-
• Training together with other services (intedisciplinary) works well for the
  social network that promotes quick work
                    Effects of training
• Individual:
  – Emotions less dominant
  – Habits productive in emergency
  – Right arguments
• Group level:
  –   Higher cohesion
  –   More trust in coworkers
  –   More mutual correction
  –   More discussion on possibilities
• Procedural effects
  – Only if a thorough evaluation has taken places and results
    are discussed in whole group
• Effects of training are easily nullified by distraction, for instance
  through new and emotional happenings [solution: training]
• When coping with an emergency, one must continually try to
  remember what was learned? This often means that one must do
  counter-intuitive things [solution: much rehearsal]
• That is not an easy thing to do, so people quickly revert to habitual
  action patterns [solution??]
• Of course the distraction effect is stronger in neophytes than in
  experienced people [solution: coupling]
• But: people with much experience think they have seen it all and thus
  know evrything that is worthwhile and thus lose much alertness and
  creativity [solution: mixed teams]
             What is the central lesson?
                    Tell anecdote of poor Polish man

From this story and from my short lecture the following lesson can be deduced:

          Perfection is impossible,
          but you you must continually
               strive for it
•   personal protective equipment,
•   mass decontamination,
•   technical decontamination,
•   evidence preservation and sampling,
•   product control,
•   air monitoring and sampling,
•   victim rescue/recovery, and
•   illicit laboratory incidents

To top