Speaking of human factors: Emergent meanings in interviews with professional accident investigators

This paper presents a qualitative analysis of the human factor concept, more specifically what it means and includes in everyday professional discourse. It is founded on 10 extensive interviews with professional investigators within the road, maritime and rail administration concerning their practical investigative work. General and specific results are generated of interview contributions using a pragmatic communicative approach and discourse analysis.Results show that human factors is an expression tied to individual professional experience, sparks dissatisfaction and demands specification due to recurring indexicality problems. It tends to be used for negative matters. The specific results, listing eight different meanings, indicate that there is no such thing as a professional usage of the human factor but a spectrum of meanings. The study concludes that the meanings of the human factor (a) always evolve in the dynamic process of producing and understanding language, (b) are context-dependent, and (c) emerge through talk, as one type of discourse. Contrary to ordinary conceptions, there is no simple matter as a human factor that may be used in a routine manner. A non-specific use of the notion may even obscure a course of events and prevent necessary investigation, for example, if the human factor simply replaces a factor such as ‘fatigue’. Although contemporary interdisciplinary research focuses peripheral factors, the idea of individual humans and their erroneous acts has survived – and lives – in the practical world of professional investigators. Empirically deduced meanings need to be continuously highlighted and problematised if theory is to approach everyday professional practice.     

Age-related accident risks among assembly workers: A longitudinal study of male workers employed in the Swedish automobile industry

This study investigates whether there is evidence of age-related accident risks among male assembly workers in the Swedish automobile industry. Age-related accident ratios (ARs) were measured for all accidents aggregated and for six accident types over a 10-year period, using five age categories and three time intervals. The results showed that regardless of accident type, ARs were generally higher among younger workers than older ones, though not for all accident types and time periods. ARs by (open) age cohorts increased over time in four accident situations out of six for assemblers aged 25–34 (35–44 in 1990–1991). Inequalities in risk exposure, labor-market factors, and early deselection from the occupation are emphasized as significant external factors in the age-related differences observed in ARs.     

The development and evaluation of accident prevention routines: A case study

Information resulting from the occurrence of accidents and near-accidents is the basis for most accident prevention efforts. However, such information may not normally be incorporated into local safety activities. A group to assist supervisors in their investigations of accidents and a procedure to prompt the reporting of near-accidents by employees were tested at one company as means of improving local safety activities. The accident investigation group was in operation in all departments and was associated with improved accident reporting and prevention activities as well as a reduction in accident severity. The near-accident reporting procedure was tested in one department and led to improved knowledge about risks, although no reductions in accident frequency and severity were shown. On the basis of these results, the company safety committee decided at the end of the first year to extend the mandate of the investigation group but not to continue with near-accident reporting. Follow-ups after 2 and 3 years indicated that improvements in prevention activities had been maintained and that accident severity had been further reduced.     

隐患治理及研究

2008年“隐患治理年”刚刚过去,但隐患治理在安全生产长效机制中的地位和作用仍是永恒主题。隐患还需要深入研究并更加科学定义,隐患称谓需要引导并规范一致,隐患在实际应用中需要结合国内安全生产特点进一步发展。隐患提出和应用的最终目的是为了事故预防,隐患需要分级,治理重大隐患才能预防重大事故。     

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.     

中国民航事故调查的客观公正探讨

为了防止同类事故重复发生、缓解社会和行业的猜忌和矛盾、提高中国在国际社会的形象和声誉,关注航空事故调查的客观公正已然迫切。从结果和过程两个方面探讨了事故调查中客观公正的内涵,分析了阻碍我国民航事故调查客观公正五个方面的影响因素,系统性提出了解决问题的途径。结果表明,从机构设置、规章建设、人员培养、工程能力、监督机制等方面加以完善,可以改进事故调查的结果客观和过程公正。     

关于一起过电压事故的调查分析

通过一起过电压事故的调查分析,找出了发生事故的主要原因,并提出了整改措施及应吸取的经验教训。     

The role of self-regulation in the context of driver distraction: A simulator study

Objective: There is considerable evidence for the negative effects of driver distraction on road safety. In many experimental studies, drivers have been primarily viewed as passive receivers of distraction. Thus, there is a lack of research on the mediating role of their self-regulatory behavior. The aim of the current study was to compare drivers' performance when engaged in a system-paced secondary task with a self-paced version of this task and how both differed from baseline driving performance without distraction.

Methods: Thirty-nine participants drove in a simulator while performing a secondary visual–manual task. One group of drivers had to work on this task in predefined situations under time pressure, whereas the other group was free to decide when to work on the secondary task (self-regulation group). Drivers' performance (e.g., lateral and longitudinal control, brake reaction times) was also compared with a baseline condition without any secondary task.

Results: For the system-paced secondary task, distraction was associated with high decrements in driving performance (especially in keeping the lateral position). No effects were found for the number of collisions, probably because of the lower driving speeds while distracted (compensatory behavior). For the self-regulation group, only small impairments in driving performance were found. Drivers engaged less in the secondary task during foreseeable demanding or critical driving situations.

Conclusions: Overall, drivers in the self-regulation group were able to anticipate the demands of different traffic situations and to adapt their engagement in the secondary task, so that only small impairments in driving performance occurred. Because in real traffic drivers are mostly free to decide when to engage in secondary tasks, it can be concluded that self-regulation should be considered in driver distraction research to ensure ecological validity.     

The safety impact of the 65 mph speed limit: A case study using Alabama accident records

On August 1, 1987, a change in Alabama laws went into effect raising the speed limit on the rural interstates to 65 mph. Two accident data sets (one year before and one year after the law change) were compared to assess the impact of the 65 mph speed limit on severity and frequency of accidents. Although accident severity appeared to remain the same from before to after time periods, the frequency of accidents on the rural interstates increased significantly, by 18.88%. However, the significant increase on the rural interstates was accompanied by a nonsignificant decrease of 456 accidents in the entire state of Alabama. This confounding result made it difficult to isolate the cause of various significant changes, but the overall evidence is not favorable to the recent increases in driving speeds.     

The role of production and teamwork practices in construction safety: A cognitive model and an empirical case study

Problem

In construction, the challenge for researchers and practitioners is to develop work systems (production processes and teams) that can achieve high productivity and high safety at the same time. However, construction accident causation models ignore the role of work practices and teamwork. This study investigates the mechanisms by which production and teamwork practices affect the likelihood of accidents.

Method

The paper synthesizes a new model for construction safety based on the cognitive perspective (Fuller's Task-Demand-Capability Interface model, 2005) and then presents an exploratory case study. The case study investigates and compares the work practices of two residential framing crews: a 'High Reliability Crew' (HRC)—that is, a crew with exceptional productivity and safety over several years, and an average performing crew from the same company.

Results

The model explains how the production and teamwork practices generate the work situations that workers face (the task demands) and affect the workers ability to cope (capabilities). The case study indicates that the work practices of the HRC directly influence the task demands and match them with the applied capabilities. These practices were guided by the 'principle' of avoiding errors and rework and included work planning and preparation, work distribution, managing the production pressures, and quality and behavior monitoring.

Summary

The Task Demand-Capability model links construction research to a cognitive model of accident causation and provides a new way to conceptualize safety as an emergent property of the production practices and teamwork processes. The empirical evidence indicates that the crews' work practices and team processes strongly affect the task demands, the applied capabilities, and the match between demands and capabilities.

Impact on Industry

The proposed model and the exploratory case study will guide further discovery of work practices and teamwork processes that can increase both productivity and safety in construction operations. Such understanding will enable training of construction foremen and crews in these practices to systematically develop high reliability crews.     

Organizational practices and workplace health and safety: A cross-sectional study in manufacturing companies

We report the results of a mail questionnaire for 312 manufacturing firms in the province of Ontario (Canada). We conducted a cross-sectional analysis of workplace level health and safety policies, practices and attitudes. Analyses were conducted across firm categories based upon lost-time frequency rate (LTFR) data. Lower LTFRs were associated with paternalistic initiatives, recording of occupational health and safety (OHS) measures, greater involvement of workers in decision-making, and better managerial attitudes concerning the importance of OHS. The composition of the Joint Health and Safety Committee (JHSC), a committee mandated in all workplaces we sampled, differed according to injury rate: the mean number of worker (vs. management) members on the JHSC was higher for lower injury sites, and the mean number of worker members attending JHSC meetings was also higher for lower injury worksites. In addition, workplaces with lower LTFR benefitted by having JHSCs with more executive functions and greater worker involvement. In conclusion, managerial and worker participation in OHS initiatives characterizes safer workplaces. Also, general concern of management towards OHS—illustrated by both attitudes and concrete actions—is also associated with lower injury rates.     

安全与事故运动规律初探

通过分析安全、隐患、事故之间的变化规律,揭示了安全与事故不仅普遍存在于自然界和人类社会活动中,具有与客观规律相依而生的自然属性,而且两者的对立统一,又具有促进客观事故向高层次发展的社会属性。     

Occupational injury and accident research: A comprehensive review

In this paper, a comprehensive review of the concepts of occupational injury and accident causation and prevention is presented. Starting with hazard identification, the issues on risk assessment, accident causation, and intervention strategies are discussed progressively. The distinctiveness and overlaps in accident and injury research are highlighted. Both empirical research in terms of hypotheses tested and theoretical research such as accident causation models are compared and contrasted. Finally, based on the critical appraisal of the comprehensive review, future research directions on occupational injury research are delineated.     

特种设备事故调查应当重视技术方法

2020年7月,某地一建材企业发生一起快开门式压力容器爆炸事故,造成1人死亡,5人受伤,直接经济损失215.98万元。4个多月后,当地发布了这起事故的调查报告,报告中对事故直接原因的描述缺少技术分析支撑,发生事故的设备有没有安全联锁装置或者安全联锁装置是否有效等情况,在事故调查报告中均未见描述,也未见这方面事故致因的技术分析,包括“导致蒸压釜釜门处于未锁死状态”的技术原因,并没有论述清楚。显然,该事故调查报告在技术分析方面存在缺失。     

一起特大冒顶事故被困人员成功抢救经验探析

本文详细介绍了四老沟矿14-3号层303盘区2309巷道冒顶事故抢救所采取的措施,并对冒顶原因进行了分析。事故发生后,采用生命探测仪探测到了被困区域还有生命迹象,对抢救工作提出了更好要求;合理调整了通风系统,避免了被困人员窒息或中毒死亡;向被困区域打钻孔,给被困人员送进了牛奶等食物,避免了被困人因饥渴而死亡;快速掘进救人通道,救出被困人员。由于决策科学、果断,措施得力,才使得8名被困人员全部脱险。详细分析了事故的原因,一是采用锚杆、无腿工字钢梁联合支护设计不合理;二是施工中存在锚杆预紧力低、托钩外露长度超长、工字钢棚数量不足等问题;三是上覆14-2号煤层采空区岩层活动及8309回采面开采动压对巷道造成了很大的影响。最后,对预防类似事故发生所采取的措施和建议做出了结论。     

核电事故中核素气溶胶烟羽扩散的模拟研究

本文选用高斯模型对放射性气溶胶扩散特性进行了模拟研究,分析了影响气溶胶扩散的主要几何参数和气象因素,探求了放射性污染物在地面上的浓度分布,最大浓度位置以及安全范围的划分等问题.模拟研究结果与相关文献相一致,证明了高斯扩散模型对此类扩散模拟的合理性和有效性;这为全面了解放射性气溶胶扩散的特性、对快速、有效地处置核事故具有指导意义.     

Age and lost working days as a result of an occupational accident: A study in a shiftwork rotation system

The present work analyzed the relationship of age and tenure with occupational accident severity of 156 male shiftworkers at an industrial plant. Based on past research, negative binomial regression analyses were performed to examine the association of age and tenure with the lost working days due to medically certified occupational accidents (LWDI). The main effects of age and tenure and the contribution of age by tenure interaction and age squared terms were examined. Regression results indicated a significant association of age by tenure interaction with LWDI. However, this relationship was non-significant when considering an age squared term in the regression equation, suggesting a non-linear association of age with LWDI. The findings are discussed in regard to the specific preventative measures of occupational accidents in shiftwork systems that could be addressed to different age groups.     

Factors associated with prehospital death among traffic accident patients in Osaka City,Japan: A population-based study

Objective: Although it is important to assess the factors associated with traffic accident fatalities to decrease them as a matter of public health, such factors have not been fully identified.

Methods: Using a large-scale data set of ambulance records in Osaka City, Japan, we retrospectively analyzed all traffic accident patients transported to hospitals by emergency medical service personnel from 2013 to 2014. In this study, prehospital death was defined as that occurring at the scene or in the emergency department immediately after hospital arrival. We assessed prehospital factors associated with prehospital death due to traffic accidents by logistic regression models.

Results: This study enrolled 28,903 emergency patients involved in traffic accidents, of whom 68 died prehospital. In a multivariate model, elderly patients aged ≥75 years (adjusted odds ratio [AOR] = 4.34; 95% confidence interval [CI], 2.29–8.23), nighttime (AOR = 2.75; 95% CI, 1.65–4.70), and type of injured person compared to bicyclists such as pedestrians (AOR = 9.58; 95% CI, 5.07–17.99), motorcyclists (AOR = 2.75; 95% CI, 1.21–6.24), and car occupants (AOR = 2.98; 95% CI, 1.39–6.40) were significantly associated with prehospital death due to traffic accidents. In addition, the AOR for automobile versus nonautomobile as the collision opponent was 4.76 (95% CI, 2.30–9.88).

Conclusions: In this population, the factors associated with prehospital death due to traffic accidents were elderly people, nighttime, and pedestrian as the type of patient. The proportion of prehospital deaths due to traffic accidents was also high when the collision component was an automobile.     

Routinization of job context and job content as related to employees' quality of working life: A study of Canadian nurses

The literature on routinization of work is both ambiguous and equivocal when its impact on quality of working life is considered. The classical management literature suggests that routinization of work has a positive influence on individual performance and by implication on the quality of working life resulting from the overall prosperity generated. However, more recent literature on job characteristics and job design argues that routinization of work has a negative impact on individual performance as it suppresses creative expression on the job. This paper suggests that these mixed findings are due to an inadequate theoretical grasp of the concept of routinization and presents empirical evidence which attempts to clarify the ambiguity. Data were collected from 1148 nurses working in anglophone hospitals in the greater Montreal area in the form of a field survey questionnaire. The results indicated that nurses who worked routine shifts perceived higher levels of quality of working life compared to those on non-routine shifts. The results also indicated that nurses who experienced high routinization in job content perceived lower levels of quality of working life compared to those nurses who experienced low routinization in job content. Implications of these findings for future research are discussed.