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.     

事故调查报告中事故原因分析的改进*——基于企业事故案例学习视角

为进一步提高我国事故调查报告的质量,更好地满足企业对事故案例学习的需要,通过案例分析事故调查报告中事故原因部分存在的问题及其原因,并在此基础上提出采用事故致因理论来改进事故调查报告的思路;应用24Model改进天嘉宜化工有限公司“3·21”特别重大爆炸事故的事故原因分析,以此来验证本文思路的可行性和有效性。研究结果表明,使用事故致因理论能够更加科学地归纳事故原因,增强措施的针对性和可操作性,可有效改善事故调查报告的质量。     

An illusion of objectivity in workplace investigation: The cause analysis chart and consistency,accuracy, and bias in judgments

Introduction: Investigation tools used in occupational health and safety events need to support evidence-based judgments, especially when employed within biasing contexts, yet these tools are rarely empirically vetted. A common workplace investigation tool, dubbed for this study the “Cause Analysis (CA) Chart,” is a checklist on which investigators select substandard actions and conditions that apparently contributed to a workplace event. This research tests whether the CA Chart supports quality investigative judgments. Method: Professional and undergraduate participants engaged in a simulated industrial investigation exercise after receiving a file with information indicating that either a worker had an unsafe history, equipment had an unsafe history, or neither had a history of unsafe behavior (control). Participants then navigated an evidence database and used either the CA Chart or an open-ended form to make judgments about event cause. Results: The use of the CA Chart negatively affected participants' information seeking and judgments. Participants using the CA Chart were less accurate in identifying the causes of the incident and were biased to report that the worker was more causal for the event. Professionals who used the CA Chart explored fewer pieces of evidence than those in the open-ended condition. Moreover, neither the open-ended form nor the structured CA Chart mitigated the biasing effects of historical information about safety on participants' judgments. Conclusion: Use of the CA Chart resulted in judgments about event cause that were less accurate and also biased towards worker responsibility. The CA Chart was not an effective debiasing tool. Practical application: Our results have implications for occupational health and safety given the popular nature of checklist tools like the CA Chart in workplace investigation. This study contributes to the literature stating that we need to be scientific in the development of investigative tools and methods.     

监测技术在深基坑地下连续墙工程中的应用

随着城市建设的发展，采用地下连续墙作为深基坑围护结构的深基础工程越来越多，它以其墙体刚度大，阻水性能好，一墙多用，并能适应多种地层条件而广泛应用于高层建筑的地下室等基础结构物的建造，本结合广州市粤财大厦地下连续墙工程，就其监测内容及监测结果进行了详细分析，结果表明，本基坑围护结构体系是安全的，达到了基坑开挖与围护工程安全与稳定的要求，对类似工程具有指导和借鉴意义。     

Migrating an incident reporting system to a CCPS process safety metrics model

A major chemical company established a formal incident investigation and reporting system several years ago. The original system focused heavily on worker-related injuries, illnesses, and near-misses and was used primarily to track statistics reportable to the Occupational Safety and Health Administration (OSHA). This Occupational Injury and Illness (OII) approach has been recognized to be an ineffective tool for measuring, predicting, and preventing process safety incidents. The Center for Chemical Process Safety (CCPS) recently published guidelines on how to establish safety metrics for the measurement and reduction of process safety incidents. The process safety metrics approach relies upon leading and lagging metrics to improve organization process safety. This paper is a case study of the analysis of one organization’s incident database, which represents approximately five years of data from over a dozen facilities. The aim of this investigation was to extract useful process safety metrics from the incident investigation and reporting system, which would be pertinent to the types of process units and process functions at these facilities. This paper will discuss the approach taken to extract process incident information from an OII-based database and present the difficulties of performing an analysis on such a database. This paper provides guidance on how to migrate an existing OII-based reporting system to a program that includes process safety metrics in accordance with industry best practices.     

Learning from accidents – What more do we need to know?

A model of experience feedback (the CHAIN model) that emphasizes the whole chain from initial reporting to preventive measures is used to identify important research needs in the field of learning from accidents. Based on the model, six quality criteria for experience feedback after an accident or incident are presented. Research on experience feedback from accidents is reviewed. The overall conclusion is that the discipline of experience feedback has not been sufficiently self-reflective. The process of experience feedback can and should be applied to experience feedback itself, but that is rarely done. Evaluation studies are needed that provide hard (evidence-based) information about the effects of various methodologies and organizational structures. Four types of studies are particularly important for the development of evidence-based accident investigation practices: (1) studies of the effects and the efficiency of different accident investigation methods, (2) studies of the dissemination of conclusions from accident investigation, (3) follow-up studies of the extent to which accident investigation reports give rise to actual preventive measures, and (4) studies of the integration of experience feedback systems into overall systems of risk management.     

数值模拟方法在壁面烧损痕迹的应用

本文作者对FDS源程序进行了改进,并利用改进后程序计算火灾过程中壁面热解形成图痕,作为火灾调查的方法之一,初步分析壁面烧损痕迹发展特征。该方法可以根据火灾场景、壁面材料、起火点功率的不同计算研究壁面燃烧痕迹形成规律,并提出使用该方法对火灾调查提供理论依据的可行性和重大意义。     

Archetypes for organizational safety

We propose an initial set of six system safety archetypes that model common dynamic organizational behaviours that often lead to accidents. The archetypes help clarify why safety-related decisions do not always result in the desired behaviour, and how independent decisions in different pans of the organization can combine to have a negative, and often unforeseen, impact on safety. Examples from the NASA manned space program and general industry are used to illustrate the archetypes. As accident analysis and investigation tools, the archetypes can be used to develop dynamic models that describe the systemic and organizational factors contributing to accidents. As risk analysis tools, the archetypes can be used to improve understanding of the ways that risk can arise in complex socio-technical systems.     

10万t锌系统电除尘器的设计与应用

对某厂采用普通型板式电除尘器处理l0万t锌沸腾焙烧烟气,在使用不到一年时间,造成设备腐蚀,甚至腐烂,严重影响了沸腾焙烧和制酸的正常生产,而被迫废弃的原因进行了较详细的叙述与剖析,并在此基础上重新设计研制了1台与实际生产相适应的GW1-55P-4 型电除尘器,于1998年9月建成并一次试车投产成功.     

火灾调查理论框架建立探讨

本文根据目前火灾科学研究的现状，提出了建立火灾调查理论框架的构想。对火灾调查研究中国外发展状况，进行了较为详细的综述，并指出目前该领域存在的问题。详细讨论了建立火灾调查理论框架的科学根据，同时探讨了火灾调查理论研究中包含的关键科学问题。     

一起立式锅炉爆炸事故原因分析及隐患排查

采用现场勘察、光谱分析和金相检验等方法对一起立式锅炉爆炸事故进行原因分析,发现该锅炉制造时存在严重未焊透的设备缺陷和其他使用管理方面的问题.为此制定了超声波检测工艺,对本地区同一制造厂生产的在用锅炉进行隐患排查.对排查发现存在严重制造缺陷的锅炉进行现场维修或召回,对排查发现的使用管理方面的问题也一并跟踪整改.     

Experimental investigation of limiting oxygen concentration of hybrid mixtures

An investigation into the limiting oxygen concentration (LOC) of fifteen combustible dusts and methane, ethanol and isopropanol hybrid mixtures in the standard 20 L explosion chamber was performed. Three ignition energies (10 J, 2 kJ and 10 kJ) were used. The results show that a 10 J electrical spark ignition leads to significantly higher limiting oxygen concentration values than either 2 kJ or 10 kJ pyrotechnic igniters. This could be due to the “overdriving” effect of the chemical igniters, which produce a hot flame that virtually covers the entire explosion chamber during combustion. With respect to hybrid mixture investigation, the 20 L sphere was modified to allow the input of methane gas and flammable solvents. The limiting oxygen concentrations of the hybrid mixtures were found to be considerably lower than those of dust air mixtures when the relatively weaker spark igniter was used. There was no significant change in limiting oxygen concentration when the higher energy chemical igniters were used.     

Rating accident models and investigation methodologies

This is a report of research to identify, rate, and rank accident models and accident investigation methodologies. Models and methodologies used in 17 selected government agencies were examined. The examination disclosed 14 accident models and 17 different accident investigation methodologies in those agencies. To determine their relative merit, evaluation criteria and a rating scheme were developed from user data, statutes, applications, and work products, and each model and methodology was rated. The ratings indicated significant differences in their relative merit. The highest rated model and methodology were tested to determine if the estimated ratings were supported by observable differences in actual performance and to compare investigative results against previously reported cases. Differences found prompted further examination of the benefits and problems that would result from implementation of the preferred model and methodology. Additional exploration of comparative performance measurement techniques disclosed further differences affecting the selection decisions. The models, methodologies, criteria, ratings, rankings, test results, and initial measurement findings are summarized in this report. Issues ranging from oversimplification to ethical questions were discovered during this work. The findings strongly suggest that significant accident investigation program changes should be considered in agencies and organizations using lower-ranked accident models or investigation methodologies and that a compelling need exists for more exhaustive research into accident model and accident investigation methodology selection decisions.     

Vocational rehabilitation programmes: A financial appraisal

This paper seeks to evaluate the efficacy of rehabilitation programs in facilitating injured workers' return to work. A major methodological problem with such investigations is the inability of the analyst to observe the counter-factual, i.e. the outcome had the worker's compensation claimant not received rehabilitation services. In this paper the results are reported of an empirical investigation of the effectiveness of rehabilitation programs undertaken by 503 injured workers. An internal control group of injured workers who fail to complete rehabilitation programs is used to assess the impact of rehabilitation. Multivariate statistical techniques are used to hold injury and socio-economic characteristics constant, and to arrive at an estimate of the probability of a successful return to work. This probability estimate is then used to ‘weight’ the potential cost saving. Our findings are that every $1 spent on rehabilitation services yields a reduction of system costs of $2.31.     

基于文本挖掘和复杂网络的事故致因重要度评估方法——以房屋市政较大以上事故为例

为充分挖掘事故调查报告中的有效信息,明确安全管理工作的内容.首先,利用文本挖掘分析事故调查报告,采用最小词频阈值文档频改进信息增益评估函数对分词结果降噪,通过回溯特征项在报告中的具体表述,提取事故致因,再构建同义词词库.然后,引入复杂网络以改进TF-IDF,综合事故致因因素的关联特征评估其重要度.最后,以房屋市政较大及...     

Study on the stability of nitroglycerine spent acid

Nitroglycerine has been widely used as an ingredient of explosives and propellants for a long time. It is produced by the glycerine nitration reaction. Many explosions have occurred during handling or storing spent acid after separating nitroglycerine from the reactor in nitroglycerine factories. Safety charts have been constructed by various authors in order to cope with these hazards. In this investigation we construct enthalpy diagrams that correspond with the safety charts produced by earlier researchers. These can be used to evaluate the variation of heat and the safety composition during the handling of spent acid. Furthermore, this study uses practical operating conditions at nitroglycerine factories to evaluate the stability of spent acids in storage.     

Modelling of dust lifting process behind propagating shock wave

Dust dispersion from a layer is a complicated problem, which has not been completely solved yet, especially if an Eulerian–Eulerian approach has to be used to model the two-phase dusty flow. In previous investigation, a phenomenological model of the dust dispersion process from a layer was developed, but the evaluation of the model revealed some weaknesses. In the current paper, the model of the dust dispersion process was presented and three improvements of the model were studied: Saffman force, Magnus force and particles collisions. The implementation of Magnus and Saffman forces into the code did not improve the numerical results and it was shown that it had very little influence on the dust lifting process, in case the phenomenological model of the layer is used. Some explanations were proposed in the paper. Besides, an empirical model of particles collisions was also added to the code and its influence on the results was studied. It was shown that the particles collisions model improved the obtained results, but further modifications are to be studied in the future.     

The context and habits of accident investigation practices: A study of 108 Swedish investigators

The context and habits of accident investigation practices were explored by means of questionnaire data obtained from accident investigators in the healthcare, transportation, nuclear and rescue sectors in Sweden. Issues explored included; resources, training, time spent in different phases of an investigation, methods and procedures, beliefs about causes to accidents, communication issues, etc. Examples of findings were: differences in the extent to which the ‘human factor’ was perceived as a dominant cause to accidents; manning resources to support investigations were perceived as rather scarce; underutilization of data from safety related processes such as risk analysis and auditing data; the phase of suggesting remedial actions (recommendations) were comparatively brief and generally not well supported. A majority of the investigators thought that the investigations were free from pressures to follow a specific direction; the investigators also thought that performing an investigation in itself (regardless of the specific results) had positive influences on safety. A majority of the investigators thought that upper management had a relatively strong influence on safety in the organizations. The results are discussed in terms of suggestions for strategies to strengthen investigation practices – particularly those conducted as part-time work in organizations.     

高速公路运营安全性评价

系统研究国内外道路运营安全评价先进技术,认为各种安全评价方法有其优缺点,单一方法使用时,难以得到全面、可靠的评价结果。在此基础上,结合我国高速公路运营状况,提出了运用速度协调性分析、事故调查与分析、设计符合性以及运营安全评价清单进行评价的高速公路运营综合安全评价方法。该方法能最大程度地发现事故隐患、预防事故的发生或减轻事故的严重程度。并运用该方法对某改建高速公路进行了运营安全评价,指出了该拟改建高速公路两处事故多发路段和3方面的安全隐患,证实了综合安全评价方法的有效性。