Measurement techniques for organizational safety causal models: Characterization and suggestions for enhancements

Through a review of literature from diverse disciplines with actual and potential application to causal modeling of organizational safety risk, this paper explores issues regarding measurement techniques in a quantitative safety analysis context. The interdependencies of modeling perspectives, constructs, and measures are indentified, leading to (a) characterization and classification of measurement techniques, (b) suggestions on the selection of appropriate measurement methods for different types of model constructs including individual-level, global, configural, and shared, and (c) discussion of the modeling implications of interactions between measurement, constructs, and causal paths. A multi-dimensional perspective is offered through combinations of different “measurement methods” and “measurement bases”. A Bayesian approach is also proposed to operationalize the multi-dimensional measurements. Examples are provided to help explain the roles of these measurements in capturing the relation between organizational factors and safety performance. This paper is a product of research which has the primary purpose of extending Probabilistic Risk Assessment (PRA) modeling frameworks to include the effects of organizational factors as the fundamental causes of accidents and incidents.     

What-You-Look-For-Is-What-You-Find – The consequences of underlying accident models in eight accident investigation manuals

Accident investigation manuals are influential documents on various levels in a safety management system, and it is therefore important to appraise them in the light of what we currently know – or assume – about the nature of accidents. Investigation manuals necessarily embody or represent an accident model, i.e., a set of assumptions about how accidents happen and what the important factors are. In this paper we examine three aspects of accident investigation as described in a number of investigation manuals. Firstly, we focus on accident models and in particular the assumptions about how different factors interact to cause – or prevent – accidents, i.e., the accident “mechanisms”. Secondly, we focus on the scope in the sense of the factors (or factor domains) that are considered in the models – for instance (hu)man, technology, and organization (MTO). Thirdly, we focus on the system of investigation or the activities that together constitute an accident investigation project/process. We found that the manuals all used complex linear models. The factors considered were in general (hu)man, technology, organization, and information. The causes found during an investigation reflect the assumptions of the accident model, following the ‘What-You-Look-For-Is-What-You-Find’ or WYLFIWYF principle. The identified causes typically became specific problems to be fixed during an implementation of solutions. This follows what can be called ‘What-You-Find-Is-What-You-Fix’ or WYFIWYF principle.     

Don't wait for accidents — possibilities to assess risk in traffic by applying the ‘Wiener Fahrprobe’

In Vienna during more than 10 years of research work a special traffic behaviour observation method has been developed, evaluated and applied by Risser et al. in the frame of many different traffic safety projects. Car drivers are accompanied by two observers who register not only errors in behaviour of drivers but also their communication and interaction with other road users. Malfunction of communication and interaction are judged as main sources for problems for danger in traffic. For example, if they lead to a bad traffic climate fealings of discomfort, anger and frustration will prevent cooperative actions of road users. Being able to recognize such negative or dangerous interaction patterns in time it seems to be easier to protect road users — most often the ‘unprotected’ ones — from getting involved in accidents. This contribution gives an impression about theory and practice of the observation method and shows results of different studies, where the method called ‘Wiener Fahrprobe’ has been applied. Furthermore it will show how the method and its results can be used in the frame of the European traffic (safety) research projects ‘PROMETHEUS’ and ‘DRIVE’. Till now no accident data exist in respect to new RTI systems. Therefore it seems to be important to have a sophisticated social-psychological method for testing the behaviour and interaction of road users in connection with these systems. This is a necessary prediction for deciding whether the systems are socially compatible or not.     

Measuring safety climate: identifying the common features

In UK industry, particularly in the energy sector, there has been a movement away from ‘lagging’ measures of safety based on retrospective data, such as lost time accidents and incidents, towards ‘leading’ or predictive assessments of the safety climate of the organisation or worksite. A number of different instruments have been developed by industrial psychologists for this purpose, resulting in a proliferation of scales with distinct developmental histories. Reviewing the methods and results from a sample of industrial surveys, the thematic basis of 18 scales used to assess safety climate is examined. This suggests that the most typically assessed dimensions relate to management (72% of studies), the safety system (67%), and risk (67%), in addition themes relating to work pressure and competence appear in a third of the studies.     

Bifocal/varifocal spectacles, lighting and missed-step accidents

Good lighting and the correct use of spectacles generally improve vision and presumably reduce the risk of accidents. However, bifocal and varifocal spectacles can increase the risk of misjudging distances when negotiating underfoot hazards. In some circumstances, the portion of the lens used for close work may inadvertently be used where accurate judgement of distance is necessary. This paper reports results from two studies of patient interviews using the Merseyside Accident Information Model; the first a study of accidents which occurred during paid employment (1504 cases) and the second of 1326 accidents mainly in domestic and leisure activities. Underfoot accidents were identified by the first unforeseen event perceived by the patient. The relationship between underfoot events and the type of spectacles worn by the patient at the time of accident was analysed. In both studies there was a significant association between accidents where the first event was ‘missed edge of’ (step) and wearing bifocal/varifocal spectacles. Corporal movements reported in both studies indicated that ‘stepping down’ when wearing bifocal/varifocal spectacles, increased the risk of ‘missed edge’ accidents. In the work environment corporal movements associated with manual handling of loads also increased the risk of ‘missed edge’ accidents when wearing bifocal/varifocal spectacles.     

The Merseyside Accident Information Model (MAIM) can reveal components of accidents that lead to attendance at fracture clinics and cause disability: a new approach to accident prevention

The objectives of this study were to identify components of accidents that cause the most disability and to discover the principal sources of injuries treated in the fracture clinics. Patients attending fracture clinics of the Royal Liverpool University Hospital were interviewed using a portable computer-based questionnaire, the Merseyside Accident Information Model (MAIM). Patients were followed up by telephone interview or letter to enquire about disability continuing after discharge. Disability was measured by the pre-accident to post-discharge changes in scores for 11 normal functions. Of the 1326 patients interviewed, 900 (68%) were successfully followed up and 37% reported disability after discharge. First events ‘tripping’, ‘slipping’ and ‘other underfoot events’ accounted for 433 patients (194 reporting disability), and ‘collapsed/fainted — no other event' for 66 patients (27 reporting disability). Activities at the time of accident most frequently associated with disability involved moving about on foot. Among first event objects, ground surfaces and underfoot hazards were reported in 35%. Sources of injuries included underfoot accidents (48%), sport (13%), and transport accidents (12%.). Underfoot accidents contributed to 58% of patients reporting disability, sport 6% and transport accidents 11%. Underfoot accidents together with ‘collapsed/fainted — no other event’ accounted for 79% of female patients reporting disability and 50% of men. Such data could be used for cost-effective targeting of preventative measures, and to study the effectiveness of accident prevention initiatives.     

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.     

What is most important for safety climate: The company belonging or the local working environment? – A study from the Norwegian offshore industry

Obtaining knowledge about factors affecting health, safety and environment (HSE) is of major interest to the petroleum industry, but there is currently a severe shortage of relevant studies. The aim of this study was to examine the relative influence of offshore installation (local working environment) and company belonging on employees’ opinions concerning occupational health and safety. We analyzed data from a safety climate survey answered by 4479 Norwegian offshore petroleum employees in 2005 on the dimensions “Safety prioritisation”, “Safety management and involvement”, “Safety versus production”, “Individual motivation”, “System comprehension” and “Competence” using one way analysis of variance (ANOVA), effect size and mixed model. The companies differed significantly for “Safety prioritisation”, “Safety versus production”, “Individual motivation”, “System comprehension” and “Competence”. The local offshore installation explained more of the safety climate than the company they were employed in or worked for did.     

Mental models of safety: do managers and employees see eye to eye?

PROBLEM: Disagreements between managers and employees about the causes of accidents and unsafe work behaviors can lead to serious workplace conflicts and distract organizations from the important work of establishing positive safety climate and reducing the incidence of accidents. METHOD AND RESULTS: In this study, the authors examine a model for predicting safe work behaviors and establish the model's consistency across managers and employees in a steel plant setting. Using the model previously described by Brown, Willis, and Prussia (2000), the authors found that when variables influencing safety are considered within a framework of safe work behaviors, managers and employees share a similar mental model. The study then contrasts employees' and managers' specific attributional perceptions. Findings from these more fine-grained analyses suggest the two groups differ in several respects about individual constructs. Most notable were contrasts in attributions based on their perceptions of safety climate. When perceived climate is poor, managers believe employees are responsible and employees believe managers are responsible for workplace safety. However, as perceived safety climate improves, managers and employees converge in their perceptions of who is responsible for safety. IMPACT ON INDUSTRY: It can be concluded from this study that in a highly interdependent work environment, such as a steel mill, where high system reliability is essential and members possess substantial experience working together, managers and employees will share general mental models about the factors that contribute to unsafe behaviors, and, ultimately, to workplace accidents. It is possible that organizations not as tightly coupled as steel mills can use such organizations as benchmarks, seeking ways to create a shared understanding of factors that contribute to a safe work environment. Part of this improvement effort should focus on advancing organizational safety climate. As climate improves, managers and employees are likely to agree more about the causes of safe/unsafe behaviors and workplace accidents, ultimately increasing their ability to work in unison to prevent accidents and to respond appropriately when they do occur. Finally, the survey items included in this study may be useful to organizations wishing to conduct self-assessments.     

Acute exposure to chemicals during ‘do-it-yourself’ activities: survey of enquiries to the Swedish Poisons Information Centre in 1996

In 1996 the Swedish Poisons Information Centre performed a follow-up study concerning poisonings related to ‘do-it-yourself’ activities. The study was supported by the National Institute of Public Health in Sweden. The objectives were to investigate and define monthly variations, route of exposure, type of products and, in particular, exposures to corrosives, age and sex groups, place of treatment, severity of symptoms, place of the accident, special risk products and risk situations. The Poisons Information Centre was contacted concerning 1609 cases, with a peak during the summer months. There was no or uncertain connection between exposure and symptoms in 117 cases. This means that 1492 cases were left to study. Inhalation and eye exposure were the predominant routes, followed by skin exposure and ingestion. Cleaning agents were the most common type of products involved. Of the 1492 cases included in the study 1033 were possible to follow up. Among these, 20–29 year olds and 30–39 year olds predominated, and there was a dominance for men. In total, 28% of those exposed were subject to medical attention, either in hospital or in outpatient clinics. According to the Poisoning Severity Score 78% had mild (grade 1) and 7% moderate (grade 2) symptoms. There were no severe intoxications and no deaths. Severity grade 2 occurred 3.6 times more often among those with exposures involving risk of corrosive damage than among others in the study population. Most accidents occurred in the home. Special risk products and risk situations were exposure to corrosive products, release of chlorine when mixing hypochlorite and acid, ‘fire-eating’, siphoning gasoline and diesel fuel, welding, and inhalation of carbon monoxide from exhaust gases. The Swedish Poisons Information Centre registered 1609 cases of poisoning accidents during ‘do-it-yourself’ activities, which means an average of four to five cases per day. Although this type of accidents is not uncommon, significant poisoning seems to be rare. Some special risk situations were identified.     

Making sense of invulnerability at work—a qualitative study of police drivers

This paper reports a qualitative study of 54 police drivers who were interviewed about their views on police driver training, driving strategies and their accident involvement. Study of the transcribed interviews indicated that officers constructed narratives of themselves as being highly aware of hazards presented by other road users and they used a variety of discursive devices to minimise their own culpability and attribute risk elsewhere. Rather than maintaining a straightforward ‘illusion of invulnerability’ they were formulating a ‘topography of risk’ in which they were responding to hazards presented by suspects or other road users. Their meticulously detailed accounts of the circumstances surrounding accidents serve to place them as knowledgeable and impartial participants and create a sense of expertise and authority. Training initiatives could profitably seek to challenge this ‘topography of risk’ and sense of authority so that drivers more fully appreciate the hazard they may present to themselves and the public.     

Investigating factors that influence individual safety behavior at work

INTRODUCTION: A qualitative study was conducted to investigate the factors that influence individual safety behavior at work. METHOD: Semi-structured interviews were conducted with participants from a variety of occupations. RESULTS: The analysis revealed several organizational and social factors that explain why individuals engage in unsafe work practices. CONCLUSIONS: The influence of organizational/social factors on safety behavior were discussed. The results suggest that important organizational factors, in addition to job design and engineering systems, may be overlooked when identifying the causes of workplace accidents. Such factors include early socialization, and the need to portray a positive image. IMPACT ON INDUSTRY: The implications for management and industry are discussed.     

Successful health and safety management. The contribution of management audit

Auditing the health and safety performance of organisations is now recognised as an essential ingredient of successful health and safety management systems. The audit protocol — the question sets—is, however, only one of a number of factors which determine the end value of auditing. The competence of auditors, their insights into the organisations subject to scrutiny, their independence and the feedback and decision making processes that help organisations to review and change the way they operate are equally important. Much of the process of auditing needs to be systematic, methodical and scientific. However the art of the informed analysis and inspired interpretation can also add value to the total management process. Auditing alone will not prevent accidents and injuries. Health and safety management systems do that. Auditing seeks to assess the efficiency effectiveness of the systems. Informed management action must then follow, to maintain and improve them. This paper outlines five essential components of health and safety management; policy making, organising, planning, performance measurement and review which provide the environment in which effective auditing systems operate. It is derived from the work of HSE's Accident Prevention Advisory Unit and the advice published in “Successful Health and Safety Management” in 1991.     

The critical re-action: Learning from accidents

How do organizations react and learn from accidents? The current paper deals with the justified necessity of acting upon, and learning from accidents. The aim is to discuss organizational dynamics and interplay, evoked and put into (re)action ‘after the fact’.The paper is part of an interview study that was designed to invite individuals to reflect back, and search for patterns in terms of how they interpret the learning impact of an accident, not just in terms of changes within their own organization that can be traced back to accidents, but for the sector as a whole. A presumption for this study was the importance to look at organizational interaction, i.e. how organizations act, affect, and speak with each other. In all 30 people from the rail and marine sector were interviewed with regard to (1) revealed changes in the aftermath of the accident, and (2) conditions for learning from accidents. Thematically, the interviews had two major accidents in Norway as a background theme: The high-speed craft MS Sleipner-accident (1999) and the railway accident at Åsta (2000).The paper reports and discusses key findings from the study, with a specific focus on the interplay between actors and parallel processes in the aftermaths of an accident.     

Risk assessment of antagonistic hazards

This paper considers the risk to major hazard plant from terrorists deliberately causing catastrophic industrial accidents. The United States of America Department of Justice [Assessment of the increased risk of terrorist or other criminal activity associated with posting off-site consequence analysis information on the internet, 2000] reports that “breaching a containment vessel of an industrial facility with an explosive or otherwise causing a chemical release may appear relatively simple to…a terrorist”. They concluded that the risk of such action is “real and credible”.

Analysis of terrorism is often hampered by its being described as ‘irrational’; one corollary would be that it is unpredictable. However, terrorism may usefully be treated as a rational behaviour and in doing so it becomes possible to assess the risks it causes.

We analyse the vulnerability of major hazard plant to terrorist attack and identify nine factors (access, security, visibility, opacity, secondary hazard, robustness, law enforcement response, victim profile, and political value) that might be used as a starting point for more formal risk assessment and management.     

Industrial accidents in spray dryer plants for dairy products in Europe

Despite the fact that the information about past accidents is an integral part of accident prevention, the information about industrial accidents is not commonly available in food and agricultural sectors. Spray dryer plants for dairy products are not an exception. The aim of this paper is the creation of the representative database for industrial spray drying accidents in order to identify their major causes. The paper is divided into 8 chapters. The first two chapters deal with the general information about technology of spray drying of dairy products. The third chapter provides the outputs from the authors' database containing records of 25 accidents in milk drying facilities in Europe. These accidents took place between 1999 and 2019 in six European countries. Based on the accident database, the most common causes of accidents were identified. Processes that can cause a fire, an explosion, or damage to environment are described in the fourth, fifth and sixth chapter. The seventh chapter deals with process, technical and organizational measures; these were discussed using literature research and the results of the accident database. The eighth chapter is the conclusion with a focus on further improvement of process safety through newly developed protective tools.     

Not drowning, waving!: Safety management and occupational culture in an Australian commercial fishing port

An ethnographic study of safety management was conducted in a commercial lobster fishing industry, in a small fishing town in Southern Australia. The objectives were to test the utility of the ethnographic method for exploring the nature of the relationship between occupational culture, workplace social organization, and safety management.Available accident data suggests this particular fishery may not have the same high incidence of occupational trauma normally attributed to commercial fishing. Changes in licensing laws and improved management of fish stocks have significantly reduced risk exposure. Participants in this study had a good understanding of their physical workplace risks, but accepted some of these with too few defences. Wear rates of personal flotation devices (PFDs) were below 1% for the study period.The paper suggests that participants do not have a strong learning culture, and links this to occupation-wide cultural assumptions, other external issues and safety management issues. Assessment of the social and cultural context of safety management can offer policy makers a ‘road-map’ to guide their interventions. The utility of ethnographic methods for this type of analysis is significant, and will be enhanced by improving the transparency of the research method.     

基于行为安全“2-4”模型的受限空间事故分析及预防

为了研究受限空间作业过程的事故特性和致因机理,指导人员有效辨识受限空间作业风险,采取正确的应急救援措施。对2012年1月至2018年12月发生的典型受限空间作业过程事故进行了统计,并根据行为安全“2-4”模型对事故致因进行了分析,改变了传统事故原因的分类方法。将事故致因从一次性行为、习惯性行为、运行行为和指导行为4个方面进行划分,将安全管理体系划分为事故的根本原因。结果表明,受限空间作业事故伤害主要来源于气体中毒或窒息,盲目施救是导致受限空间人员伤亡的主要原因。基于行为安全“2-4”模型,提出从个人行为控制和组织行为控制两个层面的受限空间作业事故防控措施,对有效预防受限空间作业和救援事故,降低事故危害程度有指导意义。     

The indirect involvement of buses in traffic accident processes

The involvement of buses in accidents usually is assessed implicitly on the basis of the direct involvement of the bus in the collision or in injury production. This paper deals with the scope and forms of indirect involvement of buses (as a sight obstruction, for example). Accidents were selected by identifying the presence of the term ‘bus’ or synonyms in the text parts of complete police reports (testimonies, statements by the persons involved, etc.) available in electronic form, then analysed in detail. Direct or indirect involvement of a bus is found in 3.6% of traffic injury accidents reported by the police in the community studied (direct involvement: 1.4%; indirect involvement: 2.2%). The different forms of indirect involvement are then described, and some possibilities of preventive measures are discussed.