1. Stephan Berndsen ICSC/ESWC Conferences 2018 Amsterdam
The perspective of the Dutch Safety Board: new challenges for improving safety? Past, present, future
Stephan Berndsen
ICSC/ESWC Conferences 2018 Amsterdam
01/11/2018
ICSC/ESWC Conferences Amsterdam

2. ICSC/ESWC Conferences 2018 Amsterdam
“I love to work,
as long as it concerns work that I love”
01/11/2018
ICSC/ESWC Conferences Amsterdam

3. Looking from my perspective of yesterday
01/11/2018
ICSC/ESWC Conferences Amsterdam

4. Managing expectations: taking the pracademic approach today
01/11/2018
ICSC/ESWC Conferences Amsterdam

5. Fatal accidents in practice: the case of the Dutch fire brigade divers
July 13, 2001, Utrecht
March 22, 2007, Urk
March 12, 2008, Terneuzen
01/11/2018
ICSC/ESWC Conferences Amsterdam

6. ICSC/ESWC Conferences 2018 Amsterdam
01/11/2018
ICSC/ESWC Conferences Amsterdam

7. Primary and secondary causes
Primary causes
Problems with the use of the signal line
Not using emergency measures to create floating capacity, such as the use of the trim vest and casting off the lead belt
Removal of the diving mask
Insufficient deployment of the reserve diver
Secondary causes
Inadequate system of risk inventory and evaluation (RI&E)
Inadequate system of practicing
Inadequate system of learning and improving diving safety
Inadequate organization, in the sense that an informal way of working was dominant;
Inadequate compliance with procedures
Systemic? We’ll come back to that.
01/11/2018
ICSC/ESWC Conferences Amsterdam

8. ICSC/ESWC Conferences 2018 Amsterdam
History of the DSB
Civil aviation Board
1937
Aviation Safety Board
1993
Dutch transport safety board
1999
Investigations in transport sector, including road transport and pipelines
Investigatory Committee
2000 Enschede fire works accident
2000 Major fire accident in bar
1992 El Al crash
2005
Dutch safety board
Permanent investigatory body that can launch investigations into disasters, accidents and near-accidents in a broader range of sectors
Law amended
01/11/2018
ICSC/ESWC Conferences Amsterdam

9. ICSC/ESWC Conferences 2018 Amsterdam
Quiz question
Who is the greatest inventor of all time? Accident. Mark Twain
01/11/2018
ICSC/ESWC Conferences Amsterdam

10. ICSC/ESWC Conferences 2018 Amsterdam
Let’s turn to page 1.
When accidents or disasters happen, the Dutch Safety Board investigates how it was possible for these to occur, with the aim of learning lessons for the future and, ultimately, improving safety in the Netherlands.
The Safety Board is independent and is free to decide which incidents to investigate.
In particular, it focuses on situations in which people’s personal safety is dependent on third parties, such as the government or companies.
In certain cases the Board is under an obligation to carry out an investigation.
Its investigations do not address issues of blame or liability.
01/11/2018
ICSC/ESWC Conferences Amsterdam

11. ICSC/ESWC Conferences 2018 Amsterdam
Organisational chart
Facts and figures
Autonomous administrative body
Set up under a Kingdom Act
Independent investigation
Budget 2018 is €12.5 mln
Board of 3 members
70 FTE
Reports
Full/short reports
Thematic studies
Quarterly report
Follow-up of recommendations
01/11/2018
ICSC/ESWC Conferences Amsterdam

12. Relation DSB – judicial authorities
Independent investigation, “same” powers as the police
Good working relations with police, together on accident site
FDR and CVR protected by law (only for safety investigation)
Investigator protected against court as witness/expert
Reports cannot be used as evidence in court
Judicial authorities have no access to DSB files
Protocols with judicial authorities
01/11/2018
ICSC/ESWC Conferences Amsterdam

13. ICSC/ESWC Conferences 2018 Amsterdam
Sectors
01/11/2018
ICSC/ESWC Conferences Amsterdam

14. ICSC/ESWC Conferences 2018 Amsterdam
Systemic perspective
01/11/2018
ICSC/ESWC Conferences Amsterdam

15. Dissertation about the dynamics of deadly governmental accidents
Struggle between parties involved
Shift from hierarchy to network
Incessant investigation cycle (5 cases, 60 separate investigations)
Discourse and tragedy:three discourses
Public discourse
Risk and error discourse
Evil discourse
01/11/2018
ICSC/ESWC Conferences Amsterdam

16. Challenges for the future
Impact on society
Governance (diffusion of responsibilities)
Learning capability
Digital transformation
Erosion of institutions
Wording for recommendations
01/11/2018
ICSC/ESWC Conferences Amsterdam

17. ICSC/ESWC Conferences 2018 Amsterdam
01/11/2018
ICSC/ESWC Conferences Amsterdam