The successes and challenges of implementing high reliability principles: A case study of a UK oil refinery

Research conducted on organisations that are able to sustain excellent safety records over long time periods suggests that there are a number of practices that organisations can adopt to achieve high levels of reliability and safety. These practices are often discussed in the context of major incidents to highlight the safety standards that high hazard organisations should try to emulate. However, previous research has predominantly focused on non-profit organisations, and comparatively little research has examined whether high reliability practices may be meaningfully applied to commercial contexts. This paper addresses this gap by using a qualitative approach to explore the types of reliability-enhancing practices implemented in a UK-based oil refinery in its attempt to achieve its ethos of ‘safe and reliable operations’. The findings illustrate the successful application of reliability-enhancing practices in several domains, including: hazard identification and control; emergency preparedness and collection; and analysis of incidents and near misses. Management commitment to safety emerged as an important factor underpinning the successful implementation of reliability-enhancing practices, highlighting its potential significance in the context of commercial organisations. However, promoting an open reporting culture and maintaining high levels of management visibility may be some of the challenges encountered by organisations striving to implement reliability-enhancing practices.     

Modern accident investigation - Four major challenges

Nowadays, ‘investigation’ is a very commonly advocated approach and consequently is becoming an umbrella concept. ‘Investigation’ includes many types of approaches on different system levels. Originating from transport accidents and crime scenes, ‘investigation’ ranges from genocide, natural disasters, via discrimination, health care to crime fighting, economic fraud and ethical questions in engineering and management. In such a changing operating environment and widespread applications, accident investigation must reassess its distinctive role, purposes and operating conditions. It must clarify and communicate its specific aims and functions and performance to such an extent that it maintains its credibility, capability and quality in the eye of professionals, politicians as well as the public. Based on an assessment of the past performance of leading investigation agencies, practical experiences during major ad hoc accident investigations and changes in the operating environment, a SWOT analysis identified several issues as internal and external challenges in the future conduct of major investigations. Finally, the article proposes several priorities, challenging each stakeholder and expert in the investigation community to contribute from its own perspective to improve accident investigation theory and practices.     

Overview of the relationship between organizational and workplace factors and injury rates

This paper summarizes data from ten studies examining the relationship between organizational and workplace factors and injury rates. The studies were identified from a systematic literature search, as well as from other sources, and were included if they reported comparisons among at least 20 workplaces. Factors that were examined in at least two studies were identified. Their relationship with injury rates was determined. It was not possible to make quantitative comparisons between studies. We looked for ‘consistency’ or ‘contradiction’ in the relationships. Among the variables ‘consistency’ associated with lower injury rates were: empowerment of the workforce (in general matters); delegation of safety activities; and an active role (in health and safety) of top management. Among the ‘contradictory’ variables were the level and use of discipline for safety violations; and several others that were contradictory only in subgroups of the same study. We discuss the limitations of synthesizing results from the diverse studies.     

我国城市灾害风险应对现状及对策研究

阐述了城市灾害的分类;从城市灾害预防与控制,应急反应与救援等方面分析我国在城市灾害风险控制与应对上的不足;提出8个方面的对策。该对策研究包括:建立城市安全规划、风险防范和危机管理法律体系;实施城市防灾减灾规划并融入城市规划中;完善城市灾害风险决策支持系统和信息管理系统;实行安全规划风险评价机制;加快防灾减灾综合管理机构建设;建立科学、完善的应急救援体系;加强安全教育和防灾减灾宣传;加强城市安全科学研究与交流。该研究结果对如何提高我国城市灾害风险预防与控制能力及应急救援水平具有重要的借鉴和指导作用。     

Protecting the planet and its people: how do interventions to promote environmental sustainability and occupational safety and health overlap?

Problem: The challenges of both occupational safety and health and environmental sustainability require large-scale behavior change for meaningful improvements to occur. Environmental sustainability, or the ‘green movement’ has received far more attention recently, and certain strategies and recommendations from interventions designed for promoting pro-environmental behaviors may inform efforts to intervene on critical behaviors for improving occupational safety and health. Method: A survey of the literature regarding behavioral interventions for both environmental sustainability and occupational safety and health was conducted. Several theoretical approaches are reviewed, and successful approaches from each domain are identified, as well as parallel challenges and points for crossover. Recommendations are provided for adapting environmental sustainability intervention approaches for occupational safety and health applications. Impact on Industry: Safety and health leaders may achieve sustainable improvements in worker safety and health by harnessing the momentum of the green movement and adapting successful intervention approaches from the environmental sustainability domain.     

Committing driving violations: An observational study comparing city, town and village

Introduction

This article compares observed driving behavior in a city, a town, and a village.

Method

Unobtrusive observations were made at intersections in each residential type. Five violation types were observed: (a) not wearing a seat belt (seat belt violation); (b) not using a safety seat for a child (safety seat violation for children); (c) not using a speaker while speaking on the phone (on-phone violation); (d) failing to comply with a ‘give way’ sign (‘give way’ sign violation); and (e) stopping in an undesignated area (undesignated stop violation). It was expected that in accordance with the anonymity hypothesis that the bigger residential areas' rate of traffic violations would be higher. The effects of the residential type, drivers' gender, and age were assessed using the multiple regression model. The stepwise method of evaluation was employed. The model converged on step 3 (Adjusted R square = 0.039). Residential type and gender contributed significantly to the model. Results: Consistent with prior research, male drivers committed more violations than female drivers. Chi-square analyses were used to test the distribution of violations by the settlement types. Overall, more drivers committed violations in the two small residential areas than in the city, with 30% of city drivers, 43% of town drivers, and 51% of village drivers committing at least one violation (χ2 (2) = 37.65, p < 0.001). Moreover, in the town and the village, a combination of one or more violations was committed more often than in the city (χ2 (1) = 34.645, p < 0.001). Accordingly, more drivers committed violations in the two small settlements (48.4%) than in the city (30.6%). Possible explanations for the observed results were provided in the Discussion section.

Impact on Industry

The conclusions of this paper are that drivers in small villages tend to disobey traffic laws. Therefore, efforts have to be made in companies to take this issue in consideration while running fleets in companies located in small places far from the center.     

煤矿企业重大灾害预防与安全保障体系构建与运行评价

为提高煤矿企业重大灾害预防与安全保障能力,以典型煤矿企业为例,深入分析企业重大灾害的孕灾环境与类型,确定诱发煤矿重大灾害事故发生的关键因素,并提出构建以“安全文化理念”为1个核心,涵盖“组织”“制度”“人员”“技术”“信息”“装备”“资金”7个要素以及“危险源预控”和“灾害应急救援”2个关键环节的整体安全保障体系;最后,利用事故树模型和层次分析法评价某典型煤矿企业历年来的灾害事故实际情况,提出相关保障体系的持续优化方案,研究结果可为煤炭行业企业开展重大灾害预防与安全保障体系的设计与构建提供参考和借鉴。     

基于风险和应急准备能力评估的 应急救援能力建设

为提升我国应对综合自然灾害的应急响应与救援能力,笔者首先指出我国目前在应急准备能力评估和应急救援能力建设方面存在的主要问题;然后以地震为例,提出应急准备能力评估的指标体系框架、指标分类及评价方法,通过评估找出现存能力差距,开展基于风险评估和应急准备能力评估的应对综合自然灾害的救援能力建设。研究表明:开展基于风险和应急准备能力评估的救援能力建设能实现重特大自然灾害快速有效响应与指挥调度能力,极大提升我国重特大自然灾害的应对能力。     

建筑设计的安全系统工程初探

建筑设计的任务是全面贯彻安全、适用、经济、美观的方针,高质量、高效率、高可靠地创造具有综合效益的现代环境。以当代世界安全科学的观点,中国建筑要充分地利用资金、资源、环境、土地外,更应关注与设计变量相关的“故障——风险——灾害”的背景及设计原则。本文以建筑工程设计的系统观点,总结多年来诸项建筑子系统的安全对策[6][7][8][9][16]等;探讨安全设计系统工程方法的框架体系;试图扩展可靠性工程、运筹学及新近发展的失误控制论等安全技术。     

重大危险源普查与建立重大事故预防控制体系

本简要介绍了重大危险源普查技术方法和北京、上海等6城市重大危险源普查结果。论述了重大事故预防控制体系要素，包括重大危险源普查(辨识)、评价、安全管理、应急计划、安全规划、安全监察，GIS网络监控系统等。     

从“3·28”王家岭煤矿透水事故抢险救援反思中国事故灾难应急准备体系

"3.28"王家岭煤矿透水事故的抢险救援,反映了中国高层领导对事故抢险高度重视、极强的社会动员和控制能力、新闻媒体深度介入、指挥协调规范有力和依靠专家科学应对等典型当代中国特色。本文通过仔细分析本次煤矿透水事故的发生及抢险救援过程,提出中国还应该在强化事故灾难"预防、预警、响应和恢复"全过程应急准备、进一步完善关键应急能力、加强应急准备体系建设规划、建立应急准备活动持续改进机制和培育积极主动的应急准备文化等方面做出进一步的努力。     

Evaluation of offshore emergency preparedness in view of rare accidents

The offshore industry in the North Sea has gone from a very high risk level for employees some 30–40 years ago, to a low level. The paper reviews the statistics briefly and discusses the implications of the low level. There has from the beginning of the operations been strong focus on emergency preparedness, due to the remoteness of the operations mostly far from shore. But there will always have to be a balance between the focus on preventative safety efforts and the extent of emergency preparedness provisions. This is discussed in detail, based on an extensive evaluation of the adequacy of emergency preparedness provisions recently performed. The main findings are presented, and the robustness and validity of the approach is discussed, together with implications of the rare major accidents.     

For whom does safety pay? The case of major accidents

Government agencies regularly use the argument that ‘safety pays’ as a way of motivating employers to attend to occupational health and safety. This paper looks at the effectiveness of this argument in the case of catastrophic hazards. It suggests that, while it may be true that safety pays in an abstract sense, this is irrelevant unless it can be shown that safety pays for relevant decision makers. All too often it does not. The article illustrates its claims by drawing on the literature on the Zeebrugge, Bhopal and Piper Alpha disasters, as well as on a study of a mine disaster in Australia.     

露天矿地质灾害应急救援智能调度系统研究*

为避免露天矿地质灾害对矿山及周边城市安全带来严重影响,提升灾害发生后的应急响应速度,以抚顺西露天矿为背景,提出西露天矿地质灾害应急救援智能调度系统的设计思路,按照“统分结合、集中管理”的模式,构建救援力量装备库、地理数据库、地质灾害链数据库,设计御灾保障体系模块及应急救援调度模块,研发地质灾害应急救援智能调度系统。研究结果表明:构建高效率的地质灾害应急救援智能调度系统具有重要的意义,可为我国露天矿山安全及防灾减灾体系建设提供实用工具。     

开展我国的热安全工程技术研究

近些年来，我国热灾害事故屡屡发生，损失巨大，受到社会的普遍关注。当今，热灾害事故的防治，是一门集基础研究、应用研究和高新技术开发为一体的综合工程研究体系。社会需求、基础研究的支持和高新技术的配合，使得开展这项研究的条件与时机己经成熟。现简略介绍热安全工程技术研究体系的结构，以及这项研究的国内外状况。     

Development of a new chemical process-industry accident database to assist in past accident analysis

Past accident analysis (PAA) is one of the most potent and oft-used exercises for gaining insights into the reasons why accidents occur in chemical process industry (CPI) and the damage they cause. PAA provides invaluable ‘wisdom of hindsight’ with which strategies to prevent accidents or cushion the impact of inevitable accidents can be developed.A number of databases maintain record of past accidents in CPI. The most comprehensive of the existing databases include Major Hazard Incident Data Service (MHIDAS), Major Accident Reporting System (MARS), and Failure and Accidents Technical Information Systems (FACTS). But each of these databases have some limitations. For example MHIDAS can be accessed only after paying a substantial fee. Moreover, as detailed in the paper, it is not infallible and has some inaccuracies. Other databases, besides having similar problems, are seldom confined to accidents in chemical process industries but also cover accidents from other domains such as nuclear power plants, construction industry, and natural disasters. This makes them difficult to use for PAA relating to CPI. Operational injuries not related to loss of containment, are also often included. Moreover, the detailing of events doesn’t follow a consistent pattern or classification; a good deal of relevant information is either missing or is misclassified.The present work is an attempt to develop a comprehensive open-source database to assist PAA. To this end, information on about 8000 accidents, available in different open-source clearing houses has been brought into a new database named by us PUPAD (Pondicherry University Process-industry Accident Database). Multiple and overlapping accident records have been carefully eliminated and a search engine has been developed for retrieval of the records on the basis of appropriate classification. PUPAD doesn’t aim to replace or substitute the well established databases such as MHIDAS and MARS but, rather, aims to compliment them.     

水电站大坝群安全应急管理协同度测度研究

针对当前水电站大坝群安全应急管理缺乏主动协同而导致资源浪费的情形,提出基于网络层次分析法(ANP)和序参量法的安全应急管理协同度的测度。首先根据文献分析归纳水电站大坝群安全应急管理过程的协同关系,构建包括5个子系统和11个序参量以及33个二级指标的水电站大坝群安全应急管理协同度测度指标体系。其次借助超级决策软件确定各个指标的权重,最后采用序参量法对安全应急管理的预防、准备、响应和恢复4个环节进行协同度测度。将此方法用于国内某流域的梯级水电站大坝群。测度结果表明:该梯级水电站大坝群安全应急管理的响应和准备两个环节各子系统的协同度最高,系统总体的协同度较低,应采取优化措施以提高系统的协同程度。     

我国堰塞湖致因分析及灾害链构建研究*

为揭示我国堰塞湖形成机理,基于堰塞湖实际案例,依据灾害链式演变规律,构建我国堰塞湖灾害链模型;以灾害链模型中各因素为节点,各因素间作用关系为边,构建我国堰塞湖灾害链演化网络模型,利用Gephi软件实现灾害链演化网络可视化和拓扑参数计算,最终确定堰塞湖防治关键因素。结果表明:持续降雨作用于山地地貌,导致山体滑坡,该类堰塞湖致因在我国较为普遍,通过加大特定地区雨量与地质环境监测力度,可有效提高我国自然灾害防治水平。     

Realistic evaluation as a new way to design and evaluate occupational safety interventions

Recent debates regarding the criteria for evaluating occupational health and safety interventions have focused on the need for incorporating qualitative elements and process evaluation, in addition to attempting to live up to the Cochrane criteria. Reflecting fundamental epistemological conflicts and shortcomings of the Cochrane criteria in evaluating intervention studies, the debate challenges the traditional (quasi-) experimental design and methodology, which are often used within safety research. This article discusses a revised ‘realistic evaluation’ approach as a way to meet these challenges.Evidence from the literature as well as examples from an integrated (leader-based/worker-based) safety intervention study (2008-2010) in a large wood manufacturing company are presented, with focus on the pros and cons of using randomised-controlled-trials and a revised realistic evaluation model.A revised realistic evaluation model is provided which includes factors such as role behaviour, leader and worker motivation, underreporting of accidents/injuries, production pressure, unplanned organisational change and accounting for multilayer effects. These can be attained through qualitative and/or quantitative methods, allowing for the use of realistic evaluation in both large and small scale studies, as well as in systematic reviews. The revised realistic evaluation model offers a promising new way of designing and evaluating occupational safety research. This model can help safety science move forward in setting qualitative and/or quantitative criteria regarding context, mechanisms and processes for single studies and for reviews. Focus is not limited to whether the expected results appear or not, but include suggestions for what works for whom, under what circumstances, in what respects and how.     

而今迈步从头越——《安全生产法》征求意见稿学习体会和修改建议

首先分析了我国《安全生产法》的发展沿革,且认真学习了目前发布的《安全生产法》征求意见稿,归纳了征求意见稿还应实现四个重点突破:必须体现以人为本的执政理念;职业危害防治应列为《安全生产法》的重要条款之一;安全生产执法监察应与公共安全及行政管理分离;应对工伤保险预防机制作出明确要求。此外,建议通过《安全生产法》的进一步修订实现我国安全生产的制度化建设:建议逐步建立安全生产分级监察管理体制;推进风险管理制度,对企业实行风险分级与分级监管;逐步提出建立安全生产监察员专业化制度;建立与国际接轨的生产安全事故统计报告系统;强化城市建设土地使用规划的风险管理和安全许可;生产安全事故应急管理应强化应急准备工作;建立独立生产安全事故调查机构和公开公正调查程序;应在《安全生产法》中明确"安全生产委员会"的组织形式和功能;生产安全事故责任追究应与激励政策相结合。