Re-constructing Safety and the relative position of Systems

Johann P Theron, Project Director; Multiply Safety; Pretoria, South Africa

Keywords: system safety, oversimplification, design for safety, organizational management, safety standards.

Abstract

Safety has long been recognized as a basic human requirement for our journey to self-actualization. But as humans achieve fulfilment they seem to change their language, which has now led to the oversimplification of safety and the emergence of a safety plateau. To prevent falling into a knee-jerk re-construction trap, a redesign of systems is necessary to replace those “parts” lost during the oversimplification processes.

However, systems evolve and have become an unknown quantity in itself and while technology presents us all with challenges in understanding these changes, it has also become necessary to get back to basics again by determining the original required system mission parameters.

Going forward and backward simultaneously is difficult and a guiding light exemplified by a new reference paradigm is needed to establish understanding of the place and priority of safety, not only with respect to technical systems, but also with respect to country systems such as States.

Re-constructing safety will not just repeat past achievements, it will motivate sustainable competitiveness by supporting a safeness ideology as opposed to the current emphasis on safety culture.

Introduction

Language oversimplification has caused human safety to deteriorate to the point where it cannot be measured and optimized any more, i.e. the safety plateau. [Beyond deaths and injuries: The ILO’s role in promoting safe and healthy jobs, Al-Tuwaijri, Fedotov, Feitshans, Gifford, Gold, Machida, Nahmas, Niu and Sandi] Sure, we do risk analysis and safety assessments, measure failures and determine statistics, but does that mean we are improving? Lord Young of the United Kingdom recently asked; “If everything is so good, why is it so bad?” Its almost like inflation, the money you earn next year will be the same as this year, despite the yearly increase. Does that mean you are oversimplifying money? Sure you do, for example, you re-prioritise your assets and expenses by cutting investments and expensive purchases, drive less with fewer holidays while you say to yourself; “Where has it all gone? Somehow money has become mystified and so has safety, until now.

Let me give you a few examples of this oversimplification from environmental, organizational and human perspectives:

1. Environmental example: The second BEA report [Bureau d’Enquêtes et d’Analyses: Update on the investigation into the Accident to flight AF 447 on 1 June 2009] from the Air France Flight 447 crash investigation has identified cloud characterization as a next step in their investigation. Why – because weather has become an unknown. Thankfully NASA measures wind speeds for Standards organizations, but it seems the weather is changing for the worse which NASA has not measured lately, especially not in the Southern Hemisphere. Subsequent flights by Air France aircraft between Brazil and France have confirmed cloud related problems in the same Atlantic Ocean area where the crash occurred [Air France jet hit trouble near AF447 crash site: Luc Lacroix, CNN, 11/12/2009]. Is the weather out of specification?
2. Organizational example: President Obama is the Commander-in-Chief of American security, but he is not in charge of safety. I am not an American but based on general media statements President Obama recently decided how to engage Afghanistan with respect to security, inclusive of sensible performance metrics [Evaluating progress in Afghanistan-Pakistan: President Obama speech as reported by Foreign Policy Magazine, 16/9/2009]. And I received an email from an American Association confirming that there is no single organization in charge of safety in the United States. I would love it if someone can prove me wrong, but in South Africa it is the same.
3. Humanity example: Genocide in Burundi/Rwanda meant the death of ± 1 million (1,000,000) people without being at war, indicating a complete absence of the sense of safety [Burundi: Double Genocide: Time Magazine 26/6/1972]. This conflict was characterized by cultural differences and it occurred regardless of borders. The oppressed in this case did not even run away, they had no warning systems, no preventive actions, no insurance, no corrective systems i.e. no risk to either the oppressed (victims) or the perpetrators. Let history show that no risk equals lots of death. I prefer a little risk myself because it keeps me alive.

The examples show that we are in trouble because we do not understand the environment, we do not understand our own organizations and neither do we understand ourselves. That is why we continue to oversimplify safety even more, towards a negative spiral with an end-scenario that is too ghastly to contemplate.

Just to confirm:

People ask me – “yes, but what do you mean by safety” – then I answer “nobody seems to know” and then people say “ah yes, but I feel quite safe thank you” followed by my question “so what’s your chance of dying today - 8.38 deaths per thousand average in the US?” [CIA World Factbook; United States Population Death Rates July 2010 estimated] You can imagine how they look at me then. Imagine I ask a marketing research organization to survey 45,039 people in Minneapolis on safety - today. The respondents will all say that everything is cool, while 24 hours later one of those persons surveyed will have died [Preliminary Semiannual Uniform Crime Report: Table 4, FBI, June-July 2008 and CIA World Factbook; United States Population Death Rates July 2010 estimated]. So tell me, do you really feel safe?

Organizations continuously state categorically: “Our safety objective is ZERO fatalities” [The Journal of the South African Institute of Mining and Metallurgy, page 535, Vol 107, August 2007] and they always fail to respond to the question of what this zero probability is. After presenting general safety probability theory to a particular anthropology educated CEO, he still demanded a ZERO fatality objective. However, he quickly qualified it by saying “only as regards to unnatural deaths”. Unnatural deaths in South Africa constitute 8.56% of yearly deaths [IHS Global Statistics Data source: Deaths in South Africa 1997 - 2007]. That is not zero in anyone’s book.

Governments promulgate punitive laws [United Kingdom Health and Safety (Offences) Act 2008, Chapter 20] against safety offenders which opposes extensive Aerospace safety lessons learnt regarding openness and honesty. European Safety Regulators have implemented punitive action for especially senior managers that fail in their safety duty and their British colleagues, the Health and Safety Executive (HSE) are contemplating the same wrt to Directors Duties [Lawyers back call for Directors Duties: HSW Magazine, 14 June 2010]. What I would like to see is what is going to happen when Air France establish that the Certification Standards required by those same agencies were insufficient to have prevented the Air France 447 crash? Regulators can very easily fall on their own swords because punitive action can go both ways.

Let me summarise: Safety has been oversimplified over time resulting in lack of coordination, loss of synergies, misdirected focus areas and a safety plateau from environmental, organizational and individual perspectives. Our language is getting worse while all assumptions in human life and behavior are grounded in our use of language. In simple terms: we are stuck.

System’s place in Safety

Putting safety into perspective requires a national view. Assuming that each nation is sovereign and accountable to itself wrt safety, its current dissemination to Government departments in South Africa may be taken as an example of safety categorization: [South African National Departments: 2010]

It is quite clear that three major safety categories emerge from disseminating safety in Government. These categories are Systems, Health and Security.   These categories are also quantifiable. It is true that Health and Security are systems on their own, but it is also true that “systems” contribute separately to safety and should therefore be seen as thé primary driving force in safety today.  Philosophically the deduction is that systems have become a force unto itself. For example, in a normal corporate organization the labor law clearly states that the “organizational system” is responsible for employee safety and neither Hospitals nor Police has anything to do with it. In fact, the Government “System” has decided that the Organizational “system” should take that responsibility, thereby becoming a quantifiable, manageable force unto itself.

The theoretic assumption from the previously identified departmental safety allocation is that a President will assume responsibility for safety and will, like all good Chief Executive Officers prepare coordinated key performance areas and metrics for his Department or Government Managers. The question is what a President’s Integrated Safety Objective could be? There should be a safety advisor or experienced government officials because a President cannot always be expected to understand such decision requirements. In the security field, such officials are known as Generals having vast knowledge and experience on their subject. In the health field, officials are known as Medical Doctors that have equally vast knowledge and experience on their subject. But in the current world there are no systems generals.

That leaves us with limited systems scenario planning where only high, middle and low roads (e.g. financial system) can be estimated. However, let us assume for the moment, that an integrated objective exists because then it may be relatively easy to deduce what the Health and Security objectives would be. But in such a case, what would the “System” objective be? We all know what Health and Security entail, but what are “Systems”?

Let me summarize the place of systems in safety: Safety can be broken down into the quantifiable categories of systems, health and security. Health and Security are represented by competent people, but there is no single competent systems representative. A system is the strongest driver of safety in the modernized world and if systems are not a known quantity, it implies that neither is safety.   

The Definition of Systems

The following definitions are available:

• Systems theory is an interdisciplinary field of science and the study of the nature of complex systems in nature, society, and science. More specifically, it is a framework by which one can analyze and/or describe any group of objects that work in concert to produce some result. [Systems Theory and Connectivism; is there a link? Cathy Anderson]
• Systems Theory sees our world in terms of 'systems', where each system is a 'whole' that is more than the sum of its parts, but also itself a 'part' of larger systems. For example, a cell is more than just a pile of molecules and itself is a part of larger systems e.g. an organ. [System Theory, Ecological and Psychological Study, Nigel Brett, 30/5/2000].
• The concept that all people, places, things and forces in the universe are integrated into a hierarchy of mutually influential matter and energy. [Systems Theory, Process Mapping for Modernization of the Coast Guard, Peter Stinson 2007]

A summary from the above definitions are proposed as follows:

“A system is all people, places, things and forces in the universe integrated into a hierarchy where each system is a whole that is more than the sum of its parts that work in concert to produce some result.”

Formal Logic reasoning determine that; “if systems is an unknown entity, then safety must also be unknown”. Resulting in the finding that Safety = [Systems] ∩ [Health] ∩ [Security]. However, if the dissemination of safety into Government is evaluated in the context described by this summarized definition of systems, it is clear that systems cannot be defined based on its individual constituents or inter relationships alone, but rather on its requirements i.e. its mission to produce some result such as safety, in combination with health and security. However, the emphasis is on Systems, therefore we need a system that produces safety in known and predictable quantities.

How do I produce safety? How does my organization produce safety? How does my country produce safety? According to the Maslow Hierarchy of Needs, safety is the second most basic need of humankind after food. [A Theory of Human Motivation: Abraham Maslow 1943] So when I talk about my mission, I automatically talk about my safety mission. We have all just forgotten or oversimplified that little part and as a result have driven our safety production onto a plateau.

Further clarification of systems is needed, where requirements generally determine form, fit and function and analysis determine physical characteristics with tolerances. If the objective of the system is a quantifiable outcome such as distance travelled within minimum and maximum variances, then top down processes will be effective. But when the required outcome is an actionable verb (or function without tolerances), then a different system definition is required. This can be characterized as a “process” system where processes are implemented rather than products. The point is that such processes produce “action” regardless if the value is high or low i.e. the process is the question, not the value.

Let me summarize the definition of systems as follows: Systems can be defined as a collection of parts that produces more than its individual parts. The definition of such a system distinguishes between systems that produce products or processes. Since safety is an action produced by processes, it will require a different approach for developing a “creating” system, to produce “created” processes.

Reference for Systems

Acknowledging that an Integrated Safety Objective won’t be viable before System Safety is addressed, it follows that re-constructing systems is required first. To re-construct Systems, a definition of the reference standard against which such construction can be measured will be needed. Figure 1 proposes such a standard:


Figure 1. Reference Standard Pyramid

The above pyramid allows a sustainable (safety) objective to be identified at the top level, to be provided directly to designers at the base of the pyramid, who will translate the objective into manageable parts mostly using system theory and typical acquisition processes. These processes include such actions as specification practices, milestone scheduling, alternative concepts, test and evaluation practices, production optimization, quality systems, configuration and maintenance. All this will include simulation, visualization, rehearsals, sensitivity analysis, safety assessments and operator cautions, instructions, manuals, tools, facilities and transport resulting in commissioning and in service implementation.

All occupational parameters are designed, optimized, delivered and maintained and supported by monitoring systems and associated metrics. The occupational and industrial environment executes reality (sometimes extremes), from where lessons are learned and archived to improve and feed the effectiveness spiral.

Occupational results are fed into the integration level where optimization, balancing and prioritization are used for efficient operational control. Externalities are assessed wrt associated compatibilities and supply network changes. Integration of production with economics, communications, environment, resources and technology allows full system situational awareness to be fed into the next level of sustainability.

Using closed loop vertical control methodology the safety pyramid allows for the management of a positive spiralling output of sustainable safety and with it profits, competitiveness and reputation. In this respect safety is a force multiplier for organizational performance and can be measured using competitiveness criteria.

An example of an internal design objective is one daily fatality in populations of 26,280.  In practise such a design objective is easily achievable (as it is the current estimated world average), while the Occupational and Integration levels may have serious negative effects on this fatality rate. The invisible hand will therefore automatically apply pressure where the most deficiencies exist. In such an organizational environment the perfect relationship between effectiveness and efficiency is exercised culminating in the positive spiral trends mentioned before.

To summarize the reference standard for systems: A reference standard is proposed to facilitate vertical bottoms-up control resulting in a positive safety spiral outcome. In pursuit of this a sustainable safety objective is determined and given to the designers resulting in a defined product with occupational instructions. Occupational experience is gained providing input to integration where optimization takes place. Once a situational awareness picture is available, it is provided to the sustainability level for comparison to the original objective resulting in updated instructions to the designers. These iterations will potentially continue indefinitely allowing continuous adaptation to new scenarios, resulting in predictable and sustainable safety outputs.

Re-designing Systems

While engineering design itself is generally a top-down exercise, the reference pyramid suggests that safety system design is bottoms-up. “Designs” used within the “system” must be designed using a standard top-down approach but the system designed to achieve sustainable safety must be designed bottoms-up in iterative fashion allowing the vertical control loop to be exercised continually.

In the same vein is the objective not part of the “system”. A safety system design is not made to manage the death of your own personnel but to manage statistics at a higher level. The objective is therefore not really “your” objective but rather your environment’s objective, or external objective. You will establish your organization’s “position” within the normal statistic distribution curve in due course and hopefully improve from there. Not achieving this objective should not make the CEO liable for criminal charges on its own. In the end, the system will actually manage itself without the CEO which means that the safety metric applied to CEO’s should have nothing to do with fatality rates.  

An outside design objective also allows re-design of the system before re-construction is implemented. This is similar to implementing a new business process where it can be operated in parallel before “switch-over” is authorized. The “system” must therefore be “re-designed” for optimal performance towards the safety objective, before it can be re-constructed.

Once a vertical safety design is defined, detail designers can use those parameters to improve top-down designs of equipment and facilities required within the system, where priority effects are required. In some cases these design efforts may encounter complex problems where standard technology research and acquisition development becomes insufficient.

In a Complex environment the organization can re-design itself using techniques proposed by Roger Martin in his book “The Design of Business”. Alternatively Chaos and Complexity theories are used to investigate new directions. However, this may not always be possible to do since most organizations are ignorant of such matters and this is where survival becomes an art, rather than a science. However, art is not legally enforceable and this may create problems for Multi-National Companies trying to use “best” practices from the 1st World in a 3rd World setting. In principle different areas or locations require different “practices”. South Africa is a good example of such differences because its life expectancy is 49 years, as compared to the American life expectancy of  >78 years.

Using chaos theory James Gleick developed a population growth bifurcation diagram consisting of steady, chaotic and self-similarity indicators where organizations have little process copies of itself (survive-ability). Using complexity system theory Dave Snowden developed a method to analyze narratives in order to detect the least significant occurrences which is now successfully used in Pakistan to manage their safety.

Where engineering statistics generally look for the most significant statistic contributor, Complex theory looks for the least significant contributor. This design method allows proper identification and understanding of safety issues. In addition however, the imperative exists that one must know what one is looking at. In order to understand such analyses a wider perspective may be required in the pursuit of safety. In support of this approach, designing for safety should consider the following aspects in order of priority:

• The Universe
• Cultures
• Optimization
• Science
• World view
• Local view
• Individual view

These aspects represent very wide to very narrow views that are closely related to maturization of humans. Hopefully we will all eventually understand “why we are here” and the same applies to organizations and countries. These aspects are mostly self explanatory but special mention is perhaps required of the Universe which most people will relate to global warming or the Ozone layer but which has a much more detailed influence on our systems.

The surprising importance of culture refers to safe traditions rather than religions where religions are understood to be an integral feature at any level of understanding. Traditions have been widely investigated for commercial purposes, initially by IBM and then for safety reasons by Boeing. One case was Korean Air that successfully improved their flight safety record by forcing all air crew to relate to each other temporarily in “American Cockpit Culture”. That meant the aircrew had to adopt a second “culture” permanently. [Korean Air Safety Concerns Grow: BBC News 23/12/1999 and Culture, Error & Crew Resource Management; Helmreich, Wilhelm, Kinect, Merrit]

The Local view describes area-based views and not country-wide perspectives. This seems to favour a decentralized cross-over from the World view to the Individual view and may affect the way city services such as water and electricity systems should be designed.  This view opposes globalization most likely due to improved control requirements of things that directly affect individual’s lives (Regionalization).

Much has been said about the American urban sprawl being ineffective, but the real issue is actually unsafe use of fertile land prohibiting agricultural development. In the case of Japan, while being very effective with urbanization, having the highest population densities and the fastest train network, they have limited agricultural areas left. It would have been much safer for them to stay on mountain slopes and get to work a little later.

The individual view is mostly used by Complexity designers and despite being manipulated by media coverage, a surprisingly wide range of opinions exist allowing the computerization of  imaging maps with valleys and mountains indicating significant opinion distributions, including safety opinions.

Allowing influences from ever-narrowing perspectives to affect design will address any apparent insignificant parameter. Outputs from such complex assessments and designs are then used by engineers for implementation of hardware and processes. What is interesting at this point is that it is quite clear that re-designing of systems should not be performed without engineering oversight. (After all, China is run by Engineers and Business Process Re-engineering is not new)

To summarize the re-design of systems: Re-design of safety systems require a bottoms-up approach while hardware systems require design from top to bottom. In some cases standard technology and development processes are insufficient which then requires different techniques such as Chaos or Complexity theories. The advantage of Complexity theories is that it detects statistically insignificant contributors to safety that may have severe effects. However, performing complexity development requires a different mindset to be successful.

Re-constructing systems

Improving safety by re-constructing systems generally require new “parts” or “processes” to be added to the existing system. The following case study describes the management re-construction of a typical residential estate:

A security residential development in South Africa is located within the Capital (Pretoria) municipal borders. Everything seemed normal but on closer investigation the following parameters caused concern:

• Crime due to outsiders
• Fraud by management agent
• Rolling power blackouts from Municipal services
• Loss of tenant electrical payments

Apart from stolen funds, the residents experienced loss of goods with the increased probability of bodily harm. This occurred within the designed bureaucracy defined by law for this type of housing called “Sectional Title Housing”. All required functions such as usage measurements, billing, repairs, insurances and reporting were implemented. But still safety was not as expected.

A safety assessment revealed a single design error: Lack of monitoring and control. The oversimplification that caused the loss of control synergies occurred when a Management Agent was “conveniently” appointed. Even though the Act made provision for Agent Management, such Management was not regulated under the same Act and was “referred” to the Agency Control Board. This exacerbated visibility of electrical power distribution resulting in debt that everyone attempted to solve through legal action. A re-design exercise defined the following:

• The Sectional Title Housing Act only regulates water supply but not electrical power. This resulted in unethical and corrupt conduct in the entire electrical supply line dumping all debt liability on the Owners Association from both the Municipality and Tenants. The Owners Association then established electrical contracts with both the Municipality and each individual owner which removed all tenants from the equation. Legal action became more effective because the correct legal instruments are now being applied.
• The Owners Association fired the Agent and assumed self management after a parallel coordinated period of 3 months. Doing this resulted in cost savings because sub-contractors responsible for repairs did not have to pay “commissions” anymore. The synergies released by self-control also positively affected security thereby reducing crime incidences remarkably. (Not in neighboring estates though)

TThe only new “part” added to the system was the electrical contract. Just by doing that, levies per square meter dropped relative to neighbouring estates making the estate a more lucrative investment target.

Comparing the designed versus actual systems under review will allow process owners to ascertain differences. Re-construction requires that the “lost” synergies caused by oversimplification be identified and replaced during the re-design phase. It is very important for the process owner to understand those synergies because it will allow better identification of future variables required for monitoring and control of system level outputs.

In addition to re-establishing the “system” to its rightful glory, the process owner will also be able to identify any force-multipliers in his system. These force multipliers are what makes his system not only effective, but also more competitive and profitable. In the case of the Owners Association, their force multiplier is electricity because they are now in control of all distribution as well as water heating systems in the estate. The implication is that electricity can be sold back to the Municipality allowing improved cost management of the estate on a sustainable basis.

Force Multipliers are not only available in organizations, but in Countries as well. The following interpretation illustrates this;

During the recent Copenhagen Climate Conference the two major (and rich) contributors to pollution were identified as America and China. There is also substantial competition and competitive behaviors raging between the two countries. Identifying force multipliers in each country is becoming an important and expensive pass-time. For example, despite China controlling Rare Earth Minerals required for new technology, Americans have a new force multiplier on the horizon called Automation. Until now automation depended on the manufacturing industry to grow economically. But technology growth in programmable logic controllers, motor drive controllers, wireless software and remote controls such as robotics has advanced the automation industry into a position where it can set its own objectives and strategic direction. For example, it can integrate with IT to enable voice or mobile phone control or it can integrate with the internet to not just monitor remote processes, but also to control remote switches in a safe manner. These capabilities allow better integration into business process systems such as SAP. Advanced automation will now allow advanced processing to take place at local level, which previously was only possible at national level.

The Company structure depicted by Figure 2 is of a military contractor currently operating in South Africa. It is an Aircraft Maintenance, Repair and Overhaul (MRO) facility for the South African Defence Force and limited private organizations and has an excellent safety record.

Figure 2. MRO Company structure

This company is also capable of aircraft design, modifications, integration and flight testing and has a more generalist than specialist approach due to the local environment. The term “Rooivalk” refers to an individual product being managed. The term “Programme Office” refers more to contracts than projects which are just a localization issue.

The structure of the Company is similar to other local corporate level military companies and information has been generalized to reflect that. Most local companies of this type therefore have these characteristics:

• Finance and ICT pays group insurance in case an employee passes away or becomes disabled. It also pays the Labor Compensation Commissioner approximately $100 per employee per year in case medical attention is required for injuries etc. The Financial Manager generally does not know that he can negotiate the lucrative insurance or compensation premiums based on actual incident data.
• Quality & SHE is responsible for occupational safety procedures such as foreign object debris, personnel attire and medical and safety records. This includes corrective actions as well as competencies of people working on aircraft. But the SHE Manager has no knowledge of the design input.
• Human Resources are responsible for training of people wrt safety but do not know the extent and training requirements of safety activities such as design assessments in the company.
• The various product lines are aware of their safety responsibilities because they are under Design Authority control.

It is clear that safety is being performed, but that its economic viability is not managed between design, production, finances and the Design Authorities. The delegation of safety, required by Labor Law, is contracted between the CEO, the Quality & SHE Manager and the Design Authority. This delegation does not include finances and training which means that insurance payouts and training costs are not linked to safety figures of merit.

Oversimplification of this safety organization has unknowingly resulted in low injury rates but with uncontrolled overheads. The financial accounting structure does not have an Expense Line item identified as safety where “all” direct and indirect safety costs are accumulated. The CEO has therefore no knowledge what the total safety costs per employee are, or whether the costs incurred were justified.

To re-construct this generic company the following measures were taken:

• Establish safety as a value in the company because it is technically strong on it
• Appoint a Systems champion
• Define an integrated safety objective with subsequent Key Performance Areas for the company and its management
• Establish an accumulative management account structure for monthly safety reports
• Negotiate premiums with the Insurers based on actual incidence records
• Ensure that all tasks are evaluated before task execution takes place (Start date Management)

The force multiplier in this case is the pre-evaluation of tasks because it defines a moment in time when all requirements for a task has to be set. This allow all risks to be tabled before execution takes place leading to pro-active corrective action wrt people, training, documentation, facilities and tools, but also clients, contract validity, and real time man-hour monitoring. This principle is called start-date management as opposed to milestone or (end date) management.

Other “parts” (previously not included due to oversimplification) but now required through re-design is an integrated business process “system” that addresses safety across departments. (Such processes are not available today).

It is evident that not all recommendations can be implemented due to lack of technology or simply lack of objectivity. But that should not stop monitoring and recording activities.

To summarize re-construction of systems: Re-constructing a system differs between types of organizations. But it is always the case that “parts” lost during the oversimplification, needs to be identified during redesign against a reference system. During re-construction, those lost “parts” are replaced with new parts followed by the identification and optimization of force multipliers. The end result is a more sustainable and profitable system that produces predictable and sustainable safety.

Summary

Safety is being oversimplified continuously resulting in safety metrics reaching a safety plateau. To correct this phenomenon it is required to replace the lost synergies or parts. This is made possible by re-designing the “system” using a bottoms-up vertical reference standard identified as the safety pyramid. The new reference allows identification of “new parts” and once reconstructed, allows the identification of force multipliers for not only establishing sustainable safety but also improving effectiveness and competitiveness of the new system i.e. a step improvement in safety will result in a step improvement in competitiveness. To establish safety as a controllable parameter requires the following steps:

1. Establish separate champions for Health, Security and Systems.
2. Develop integrated safety objectives by coordinating health, security and systems activities.
3. Focus on systems development to optimize safety in relation to the safety pyramid.
4. Redesign systems not conforming to safety pyramid in order to replace lost parts.
5. Reconstruct relevant systems to maximize the force multiplier effect.
6. Repeat steps 1 to 5.

References

1. Al-Tuwaijari, Dr Sameera et al: Beyond deaths and injuries: The ILO’s role in promoting safe and healthy jobs, June 2008
2. Anderson, Cathy; Systems Theory and Connectivism; is there a link? http://www.cathyandersonblog.com/?cat=44
3. Brett, Nigel; System Theory, Ecological and Psychological Study, 30/5/2000 http://www.webnb.btinternet.co.uk/deep.htm#_Toc482714834
4. Bureau d’Enquêtes et d’Analyses: Update on the investigation into the Accident to flight AF 447 on 1 June 2009
5. CIA World Factbook; United States Population Death Rates July 2010 estimate https://www.cia.gov/library/publications/the-world-factbook/geos/us.html
6. FBI, Preliminary Semiannual Uniform Crime Report: Table 4, June-July 2008 http://www.fbi.gov/ucr/2009prelimsem/index.html
7. CIA World Factbook; United States Population Death Rates July 2010 estimated
8. HSW Magazine: Lawyers back call for Directors Duties: HSW Magazine, 14 June 20 (Propriety Information http://www.healthandsafetyatwork.com/hsw/lawyers-back-call-for-directors-duties )
9. IHS Global Statistics Data source: Deaths in South Africa 1997 - 2007 (Propriety Information)
10. Lacroix, Luc, CNN: Air France jet hit trouble near AF447 crash site, 11/12/2009
11. Maslow, Abraham; A Theory of Human Motivation, 1943.
12. Obama, Presidential speech on 27 March 2009 (as reported by Foreign Policy 16 September 2009) Evaluating progress in Afghanistan-Pakistan.
13. South African Institute of Mining and Metallurgy, Journal page 535, Vol 107, August 2007
14. South African National Departments: 2010, www.info.gov.za/aboutgovt/index.htm
15. Stinson, Peter; Systems Theory, Process Mapping for Modernization of the Coast Guard, 2007 http://www.slideshare.net/pastinson/process-mapping-for-modernization
16. Time Magazine, Burundi: Double Genocide: 26/6/1972
17. http://www.time.com/time/magazine/article/0,9171,906083,00.html
18. United Kingdom Health and Safety (Offences) Act 2008, Chapter 20
19. Wood, Andrew; Korean Air Safety Concerns Grow: BBC News 23/12/1999 http://news.bbc.co.uk/2/hi/asia-pacific/575544.stm
20. Helmreich et al; Culture, Error & Crew Resource Management; University of Texas

Biography

Johann P Theron
PO Box 11527
Hennopsmeer
0046
South Africa
www.johanntheron.co.za
+27718813577 (Mobile)
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Johann P Theron has a light-current Engineering qualification from the Tshwane University of Technology (Pretoria) and 20 years experience in South African Military Programmes ranging from Engineering Logistics, Project Management, Operations Research and RAMS Engineering. He is now the Project Director at Multiply Safety Advisors responsible for transferring competitive safeness knowledge to Executive Officers.