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C7RKY's profile
John Clarke
John Clarke
John Clarke
@C7RKY

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John Clarke

@C7RKY

Of course views all mine. All without prejudice. Just a regular chap after all. Oh...and RT's may equally imply ridicule as endorsement.

UK
Joined December 2011

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    1. Steven Shorrock‏ @StevenShorrock Jan 3

      Steven Shorrock Retweeted John Clarke

      The probability of a never event is also approx. 3 x 10-5 (1 per 31,144 procedures; Simcock, 2018). About as reliable as you’d find in any field of work, esp. complex work. The term itself is problematic and incompatible with risk-based (ALARP) approach.https://twitter.com/c7rky/status/948169919266422784 …

      Steven Shorrock added,

      John Clarke @C7RKY
      Replying to @K_G_Spearpoint @MarkGaze and 3 others
      Yes... I wasn't particularly happy when they moved away from the original 8 Never Events. Given my personal interest was in wrong site surgery, it seemed in many ways to dilute the seriousness of the message, as the list got longer.
      2 replies 6 retweets 10 likes
      Show this thread
    2. Steven Shorrock‏ @StevenShorrock Jan 3

      If the only permissible calculated risk is zero, then the only approach is to stop all operations. An alternative approach is to identify Always Conditions, which must always be met (e.g., re : staffing, equipment, beds, competency/expertise, rostering, demand & flow management)

      2 replies 14 retweets 19 likes
      Show this thread
    3. John Clarke‏ @C7RKY Jan 3
      Replying to @StevenShorrock

      At no point have I seriously expected Never Events to never happen. That said, I'm still rather fond of the term, as I always thought it captured the extreme nature of the negligence involved. If safety procedures were ALWAYS followed, never events are supposed to be impossible.

      1 reply 0 retweets 0 likes
    4. Steven Shorrock‏ @StevenShorrock Jan 3
      Replying to @C7RKY

      But the data show that: The probability of Never Events is as low as for any complex task in any industry (human reliability doesn’t get much better than 99.997%) Resources are often suboptimal/not as designed/imagined (e.g. checklist implementation, staffing, workload, pressure)

      2 replies 1 retweet 3 likes
      John Clarke‏ @C7RKY Jan 3
      Replying to @StevenShorrock

      I've already said I don't expect zero. And yet the aviation industry managed to avoid killing a single passenger anywhere in the world last year? Are they just better at doing what they're ALWAYS supposed to do?

      5:54 AM - 3 Jan 2018
      1 reply 0 retweets 0 likes
        1. New conversation
        2. Steven Shorrock‏ @StevenShorrock Jan 3
          Replying to @C7RKY

          Yes, I know. But “never” means zero. Aviation death risk is extremely low (esp. for commercial scheduled passenger), but about 100x less complex, lower demand/pressure, better resourced, and less messy generally (not starting with a sick airplane).

          1 reply 1 retweet 2 likes
        3. Steven Shorrock‏ @StevenShorrock Jan 3
          Replying to @StevenShorrock @C7RKY

          Also vastly different safeguards in aviation. There have been, e.g., landing on or taking off from taxiways, landing wheels up, running off end of runways, clipping wings when taxiing, losses of separation, but a little bit of blue sky, plane itself or pilot protects passengers.

          2 replies 1 retweet 1 like
        4. Steven Shorrock‏ @StevenShorrock Jan 3
          Replying to @StevenShorrock @C7RKY

          In healthcare, comparable events to these occur and there is no comparable safeguards. But there are annually reviewed ‘Top 5’ priorities (comparable to Never Events) which are approached via safety risk studies.http://www.eurocontrol.int/news/top-5-atm-operational-safety-studies-now-available …

          0 replies 1 retweet 3 likes
        5. End of conversation

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