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Harnessing the Power of Failure : Using Storytelling and Systems Engineering to Enhance Organizational Learning /
In this book the authors employ the SFCS approach to explore a vast array of failure events in multiple sectors of transportation, industry, aerospace, construction, and critical infrastructure.
| Clasificación: | Libro Electrónico |
|---|---|
| Autores principales: | , |
| Formato: | Electrónico eBook |
| Idioma: | Inglés |
| Publicado: |
Bingley, UK :
Emerald Publishing Limited,
2018.
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| Edición: | First edition. |
| Temas: | |
| Acceso en línea: | Texto completo |
Tabla de Contenidos:
- Intro; HARNESSING THE POWER OF FAILURE: USING STORYTELLING AND SYSTEMS ENGINEERING TO ENHANCE ORGANIZATIONAL LEARNING; Contents; Acknowledgments; About the Authors; Prologue; Part I: Introduction and Overview; Overarching Goals; Entertain; Understand the Lessons of Failure; Develop a Systems Perspective; Recognize Danger; Improve Decision Making; Provide Action-based Response to Failure Events; Facilitate Organizational Development; Layout and Flow; Part II: System Failure Case Studies; Case Study Format; Background; Proximate Cause(s) and Event Chain; Underlying Issues / Factors
- Aftermath / Response and RecoveryDiscussion and Applicability; Questions for Discussion; Quick-Look Guide; That Sinking Feeling; Background; EDT Rupture. Since February 2001, the starboard (right-side) EDT had been shut down and isolated from the rest of the system for repairs, leaving only the port (left-side) EDT for operations. But on March 14, for unknown reasons, the port EDT pump took an
- Upper-Level Gas Explosion. An estimated 1,300 m3 of gas escaped the burst EDT and collected on the upper levels of the platform. Meanwhile, the firefighting water supply experienced low pressure because the damaged seawater service pipe was flooding the cThe Tipping Point. Flooding progressed through the ventilation shafts which linked every room on every level of the column. Doors to the ballast tank and stability box (accessed through the column) had been left open for a scheduled inspection and flooded; Proximate Cause; Underlying Issues
- Lack of Training and Communication. Both the Inquiry Commission and the oil workers' union (FUP) cited deficiencies in the procedures and training to deal with emergency-situation stability and ballast. The Inquiry Commission reported that when the ballasAftermath; Discussion / Applicability; Questions for Discussion; Lewis Spins Out of Control; Background