{"id":976,"date":"2017-11-30T20:00:49","date_gmt":"2017-11-30T20:00:49","guid":{"rendered":"https:\/\/balmertcom.com\/?p=976"},"modified":"2019-01-22T19:44:48","modified_gmt":"2019-01-23T00:44:48","slug":"effect-and-cause","status":"publish","type":"post","link":"https:\/\/balmert.com\/fr\/2017\/11\/30\/effect-and-cause\/","title":{"rendered":"Effet - et cause"},"content":{"rendered":"
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"Dites-le comme c'est<\/em>. "<\/em><\/p>

~ Howard Cosell<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t

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Le ciel \u00e9tait sombre, la lune \u00e9tait relativement claire, le temps \u00e9tait agr\u00e9able avec une visibilit\u00e9 illimit\u00e9e et une mer calme. Alors que trente-cinq marins se reposaient dans leurs casiers dans l'unit\u00e9 d'amarrage 2, leur destroyer \u00e9tait sur une trajectoire de collision avec l'ACX CRYSTAL, un porte-conteneurs trois fois sa taille.<\/span><\/p>

La collision a \u00e9t\u00e9 ressentie dans tout le navire.<\/span><\/p>

Les observateurs sur le pont ont \u00e9t\u00e9 secou\u00e9s de leurs stations, jet\u00e9s de leurs pieds. Certains pensaient que le navire s'\u00e9tait \u00e9chou\u00e9,\u00a0<\/span>tandis que d'autres craignaient d'avoir \u00e9t\u00e9 attaqu\u00e9s. Les marins dans certaines parties du navire \u00e9loign\u00e9es du point d'impact l'ont compar\u00e9 \u00e0 un tremblement de terre. Les plus proches du point d'impact l'ont d\u00e9crit comme une explosion.<\/span><\/p>

Quelques secondes apr\u00e8s l'impact, les marins de l'accostage 2, situ\u00e9 sous la ligne de flottaison du navire, ont commenc\u00e9 \u00e0 crier: \u00abDe l'eau sur le pont!\u00bb et "Sortez!" Un marin en a vu un autre renvers\u00e9 de son \u00e9tag\u00e8re par l'eau. D'autres ont commenc\u00e9 \u00e0 r\u00e9veiller les camarades qui avaient dormi pendant l'impact initial. Au moins un marin a d\u00fb \u00eatre tir\u00e9 de son \u00e9tag\u00e8re et dans l'eau avant de se r\u00e9veiller. Les matelots seniors ont v\u00e9rifi\u00e9 s'il y en avait encore dans leurs casiers.<\/span><\/p>

Les occupants du poste d'amarrage 2 ont d\u00e9crit un espace inondant rapidement, estimant plus tard que l'espace \u00e9tait presque inond\u00e9 en l'espace de 30 \u00e0 60 secondes. Au moment o\u00f9 le troisi\u00e8me marin \u00e0 partir est arriv\u00e9 \u00e0 l'\u00e9chelle, l'eau \u00e9tait d\u00e9j\u00e0 \u00e0 la taille. Des d\u00e9bris, y compris des matelas, des meubles, un v\u00e9lo d'exercice et des casiers muraux, flottaient dans les all\u00e9es entre les supports, emp\u00eachant les marins de descendre de leurs supports pour sortir de l'espace. La liste de 5 \u00e0 7 degr\u00e9s du navire \u00e0 tribord a augment\u00e9 la difficult\u00e9 pour les marins de traverser l'espace du c\u00f4t\u00e9 tribord au c\u00f4t\u00e9 b\u00e2bord.<\/span><\/p>

Un marin s'est \u00e9chapp\u00e9 par le c\u00f4t\u00e9 tribord. Ce marin a essay\u00e9 de quitter son casier, le panier sup\u00e9rieur dans la rang\u00e9e la plus proche du coffre d'acc\u00e8s tribord, mais a frapp\u00e9 quelqu'un par inadvertance, alors il a ramp\u00e9 dans son casier et a attendu jusqu'\u00e0 ce qu'il pense que tout le monde serait sorti. Quand il a saut\u00e9 de son \u00e9tag\u00e8re quelques secondes plus tard, l'eau \u00e9tait \u00e0 la hauteur de la poitrine et montait, atteignant pr\u00e8s du sommet de sa couchette.<\/span><\/p>

Le marin a eu du mal \u00e0 atteindre le point de sortie tribord, luttant \u00e0 travers les meubles de salon et contre la mer entrante. Quelqu'un a dit: \u00abAllez, allez, allez, c'est bloqu\u00e9\u00bb, mais il \u00e9tait d\u00e9j\u00e0 sous l'eau. Il perdait le souffle, mais trouva une petite poche d'air. Apr\u00e8s quelques respirations dans la petite poche d'air, il prit finalement une derni\u00e8re inspiration et nagea.<\/span><\/p>

Il a perdu connaissance et ne s'est pas souvenu de la fa\u00e7on dont il s'\u00e9tait \u00e9chapp\u00e9, mais il est finalement sorti de l'inondation dans le poste d'amarrage 1, o\u00f9 il pouvait se lever et respirer. Il a escalad\u00e9 l'\u00e9chelle de sortie de la couchette 1, \u00e0 travers un sas ouvert \u00e9tanche et s'est effondr\u00e9 sur le pont principal. Il \u00e9tait le seul marin \u00e0 s'\u00e9chapper par le point de sortie tribord.<\/span><\/p>

Le dernier marin \u00e0 \u00eatre retir\u00e9 de la couchette 2 \u00e9tait dans la salle de bain au moment de la collision: un flot d'eau l'a jet\u00e9 au sol. Des casiers flottaient devant lui et il les traversa vers la principale zone d'accostage. \u00c0 un moment donn\u00e9, il a \u00e9t\u00e9 coinc\u00e9 entre les casiers et le plafond, mais a pu atteindre un tuyau dans le plafond pour se lib\u00e9rer. Il se dirigea vers la seule lumi\u00e8re qu'il pouvait voir, venant du sas \u00e9tanche b\u00e2bord. Nageant vers le couloir \u00e9tanche, il fut tir\u00e9 de l'eau, le visage rouge et les yeux inject\u00e9s de sang. Il a rapport\u00e9 qu'en prenant son dernier souffle avant d'\u00eatre sauv\u00e9, il \u00e9tait d\u00e9j\u00e0 submerg\u00e9 et respir\u00e9 dans l'eau.<\/span><\/p>

\u2026\u2026 ..<\/span><\/p>

Prose d'un thriller de Tom Clancy? Le sc\u00e9nario d'un film d'action sur la Seconde Guerre mondiale? Nan. Chacun de ces mots a \u00e9t\u00e9 tir\u00e9 directement d'un rapport d'enqu\u00eate: l'enqu\u00eate de l'US Navy sur deux collisions distinctes, entre ses destroyers et ses navires commerciaux. Les deux se sont produits au milieu de la nuit dans le Pacifique, \u00e0 des semaines d'intervalle. Chacun d'eux \u00e9tait qualifi\u00e9 de \u00abcollision \u00e9vitable\u00bb - les deux co\u00fbtant dix-sept vies.<\/span><\/p>

C'\u00e9tait l'effet.<\/span><\/p>

Quant \u00e0 sa cause, selon les termes du rapport d'enqu\u00eate, c'\u00e9tait \u00abl'\u00e9chec des dirigeants\u00bb \u00e0 \u00abplanifier\u00bb \u00abadh\u00e9rer\u00bb \u00abex\u00e9cuter\u00bb et \u00abr\u00e9pondre\u00bb.<\/span><\/p>

Rapports de lecture<\/b><\/span><\/p>

Dans mon travail, j'ai lu beaucoup de rapports sur des \u00e9v\u00e9nements - n\u00e9gatifs - qui se produisent dans les op\u00e9rations du monde entier. Quelques-uns font les gros titres; la plupart sont des \u00e9v\u00e9nements qui n'appara\u00eetront jamais sur l'\u00e9cran radar du PDG. Dommage: si plus de ces \u00e9v\u00e9nements mineurs, m\u00eame non \u00e9v\u00e9nementiels, avaient fait leur chemin jusqu'au bureau du grand patron, je garantirai que la plupart de ces \u00e9v\u00e9nements qui font la une des journaux ne se seraient jamais produits.<\/span><\/p>

Exemple concret: ces collisions. Parmi les vingt et un r\u00e9sultats de l'enqu\u00eate figurait ce joyau: \u00abLe commandement du leadership n'a pas favoris\u00e9 une culture d'auto-\u00e9valuation critique. \u00c0 la suite d'une quasi-collision \u00e0 la mi-mai, les dirigeants n'ont fait aucun effort pour d\u00e9terminer les causes profondes et prendre des mesures correctives afin d'am\u00e9liorer les performances du navire.<\/span><\/p>

En pratique, l'effet d\u00e9termine le degr\u00e9 d'int\u00e9r\u00eat \u00e0 d\u00e9couvrir sur la cause. Avoir un grand \u00e9v\u00e9nement, une grande enqu\u00eate suivra de mani\u00e8re pr\u00e9visible, mais pas pour un quasi-accident. Dommage, car cela laisse beaucoup de causes importantes \u00e0 d\u00e9couvrir\u2026. jusqu'\u00e0 ce qu'il soit trop tard.<\/span><\/p>

Donc, en plus de ces autres \u00e9checs de leadership - planifier, adh\u00e9rer, ex\u00e9cuter et r\u00e9pondre - ajoutez celui-ci \u00e0 la liste: l'incapacit\u00e9 du leadership \u00e0 comprendre que, pour les \u00e9v\u00e9nements et les non-\u00e9v\u00e9nements, leur diff\u00e9rence se trouve en effet - pas leur cause.<\/span><\/p>

C'est aussi simple que \u00e7a.<\/span><\/p>

Effet et cause: un monde diff\u00e9rent<\/b><\/span><\/p>

Si les dirigeants du monde entier - des capitaines de navires aux capitaines d'industrie - comprenaient cette simple v\u00e9rit\u00e9 sur les causes et les effets, le monde des enqu\u00eates sur les probl\u00e8mes serait bien diff\u00e9rent. Les rapports quasi-manqu\u00e9s ne seraient pas tant consid\u00e9r\u00e9s comme un indicateur avanc\u00e9 qu'ils seraient consid\u00e9r\u00e9s comme un excellent moyen de comprendre et de pr\u00e9venir des probl\u00e8mes plus importants. L'enqu\u00eate deviendrait une comp\u00e9tence de base en leadership: si vous n'\u00eates pas dou\u00e9 pour d\u00e9terminer ce qui n'a pas fonctionn\u00e9, vous n'avez probablement pas un avenir radieux en gestion. Les superviseurs et les gestionnaires aimeraient entendre parler des probl\u00e8mes de leurs abonn\u00e9s - tout autant qu'ils aiment entendre parler des bonnes choses.<\/span><\/p>

Et les rapports eux-m\u00eames - qu'il s'agisse d'un succ\u00e8s ou d'un \u00e9chec - feraient une bonne lecture. N'importe qui dans l'\u00e9quipe pouvait prendre un rapport, comprendre ce qui ne fonctionnait pas et appr\u00e9cier ce qu'il fallait faire pour \u00e9viter que cela ne se reproduise. Ici - ou n'importe o\u00f9 ailleurs dans la tenue, n'importe o\u00f9 dans le monde.<\/span><\/p>

Ce serait en effet un monde meilleur. Et finalement un plus s\u00fbr.<\/span><\/p>

Le dire comme il est<\/b><\/span><\/p>

Sur la question importante de la conduite d'enqu\u00eates efficaces, le rapport d'enqu\u00eate de la marine devrait \u00eatre une lecture obligatoire. En plus de quarante ans de lecture de rapports d'enqu\u00eate, celui-ci est le meilleur. Le r\u00e9cit de la Marine sur les deux \u00e9v\u00e9nements a \u00e9t\u00e9 r\u00e9dig\u00e9 de mani\u00e8re \u00e0 ce qu'un civil ordinaire - vous et moi, par exemple - puisse parfaitement comprendre. Pas de jargon, pas d'acronymes; tous les termes pertinents d\u00e9finis. Les images et les dessins donnaient une image parfaite - mais pas jolie - de ce qui n'allait pas.<\/span><\/p>

Lorsqu'il s'agissait de trouver une cause, il n'y avait aucun terme populaire de l'art de la gestion - processus, syst\u00e8me, culture - pour d\u00e9tourner la responsabilit\u00e9 des individus. Pas de termes intelligents en science du comportement - \u00abesp\u00e9rance de s\u00e9curit\u00e9\u00bb n'\u00e9tant que le dernier - qui confondent plut\u00f4t que clarifient. La Marine ne se cachait pas non plus derri\u00e8re \u00abclass\u00e9e\u00bb ou \u00abprivil\u00e9gi\u00e9e et confidentielle\u00bb. Ils vivent dans le m\u00eame monde litigieux que vous et ils auraient pu le faire.<\/span><\/p>

Au lieu de cela, la marine a d\u00e9cid\u00e9 de \u00abdire les choses telles qu'elles sont\u00bb. En fin de compte, cette enqu\u00eate expose tous les \u00e9checs de ceux dont les empreintes digitales ont \u00e9t\u00e9 trouv\u00e9es sur les causes de deux \u00e9v\u00e9nements tragiques: ceux qui veillent et leurs dirigeants.<\/span><\/p>

Dans mon livre, ce n'est pas un bl\u00e2me; c'est \u00eatre honn\u00eate au sujet des faits et des \u00e9checs. Si ces marins \u00e9taient vos enfants, fr\u00e8res et s\u0153urs, parents ou amis, vous ne voudriez rien de moins que cette v\u00e9rit\u00e9.<\/span><\/p>

Enfin, dans l\u2019esprit de dire les choses telles qu\u2019elles sont, nous pourrions tout aussi bien r\u00e9v\u00e9ler l\u2019autre v\u00e9rit\u00e9 incontournable sur les causes de ces effets sur la s\u00e9curit\u00e9 auxquels vous devez faire face, des quasi-accidents aux trag\u00e9dies. Il n'y a que deux causes \u00e0 choisir: les actes de Dieu - ou les humains.<\/span><\/p>

En mati\u00e8re de cause \u00e0 effet, c'est vraiment aussi simple que cela.<\/span><\/p>

Paul Balmert<\/span><\/p>

Novembre 2017<\/span><\/p>

<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>","protected":false},"excerpt":{"rendered":"

Dans le bulletin intitul\u00e9 Managing Safety Performance News de ce mois-ci, Paul se penche sur certains de ces \u00e9v\u00e9nements r\u00e9cents pour voir ce que nous pouvons utiliser au travail pour nous assurer que tout le monde rentre chez lui bien vivant \u00e0 la fin de chaque journ\u00e9e.<\/p>","protected":false},"author":1,"featured_media":975,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center 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