The prevention of occupational injuries in two industrial plants using an incident reporting scheme

INTRODUCTION: The aim of this study was to examine whether the introduction of an incident reporting scheme with feedback in two industrial plants had an effect on the number of major incidents. METHOD: An intervention design with measurements before the implementation of the incident reporting scheme and two years later was used to examine the relationship between incident rates, safety climate, the willingness to report incidents and perceived management commitment to safety. RESULTS: The results showed that a successful implementation of an incident reporting scheme was followed by a decline in the incidence of major incidents at a Danish metal plant. A key factor in implementing the scheme was top management commitment, which was lacking at another plant, where the implementation of a similar scheme failed. CONCLUSION: Although the study shows some encouraging results concerning the use of incident reporting schemes to prevent occupational accidents, the possibility to draw causal conclusions is limited in the present study, and further studies are needed before the effectiveness of such schemes can be evaluated with certainty.     

Recognition primed decision making and the organisational response to accidents: Überlingen and the challenges of safety improvement in European air traffic management

The pioneering work of Rasmussen, Reason and their colleagues has greatly improved our understanding of the longer term causes of adverse events in safety-critical systems. Far less attention has been paid to the organisational decision making that characterises the response to accidents and incidents. Therefore, this paper examines the interventions by national and international agencies after one of the most serious accidents in European Air Traffic Management. Insights from Naturalistic Decision Making (NDM) and Recognition Primed Decision Making (RPDM) are used to explain the complex ways in which technical, organisational and political constraints shape and support the decisions and actions taken by different agencies. These constraints affect national and international safety organisations in the aftermath of major accidents. In particular, this paper uses NDM and RPDM to assess the interventions made by Swiss Federal agencies and by the Air Navigation Service provider (ANSP) following the Überlingen mid-air collision in July 1st 2002. Later sections show that there are strong similarities between the technical, organisational and political constraints that informed their decisions and the factors that directed the work of the European Organisation for the Safety of Air Navigation (EUROCONTROL). Some of EUROCONTROL’s safety responsibilities (i.e. the safety regulation elements) will in the future pass to the European Aviation Safety Agency (EASA), an Agency of the European Commission. This transfer of responsibilities has the potential to increase the powers available to ensure the implementation of recommendations following future accidents. At the same time there is a danger that key aspects of existing safety and regulatory activities may be overlooked. It is critical, therefore, that the same level of audit and monitoring be conducted on the European agencies during the transition period as is proposed for service providers and national regulatory agencies. It is important to ensure that these changes do not inadvertently lead to the loss of insights from previous adverse events.     

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.     

Worker-fatigue contributing to workplace incidents in New Zealand Forestry

ProblemReports of incidents in dangerous work environments can be analysed to identify common hazards, in turn aiding in the prevention of future accidents. Whilst studies exist that do this, most focus on causes that involve physical risks. In this paper we propose an alternative approach, and illustrate causes of forestry incidents from the perspective of worker-failure and fatigue. Method This paper outlines the analysis of eight years’ worth of New Zealand forestry incident data, with a focus on the cause of, and time that, incidents occur. Results This has resulted in two main findings. First, 70% of incidents can be attributed, at least in part, to worker-failures. Second, 78% of worker-failure based causes show indications of fatigue. This indicates that a significant number of forestry incidents are caused by worker-fatigue. Finally, this dataset showed inconsistencies in data quality, similar to those that exist in other datasets. This did not affect our analysis. However, these types of errors have the potential to affect the data quality in the national reporting system. Impact on industry The results from this study will be used in a larger project on detecting fatigue in forestry workers for injury and incident prevention. It is also our hope that other researchers may find these results of interest for further fatigue prevention research in hazardous industries.     

民航安全信息个体自愿报告意愿的影响因素研究

在前人研究成果的基础上,选择认知水平、同事顾虑、上级领导抵触、利己考虑、集体考虑、系统本身、安全文化7个影响因素,并依据SCASS分类标准,将上报意愿分为6个维度(报告提交经验、航空器不良运行或设备缺陷报告提交意愿、自身违规差错报告提交意愿、空防安全事件或隐患报告提交意愿、执行标准或飞行程序困难事件报告提交意愿、同事发生此类事件报告提交意愿),构建并验证个体自愿上报意愿的影响因素模型。研究发现,各类事件上报意愿分别受到不同的因素影响,其中,认知水平和安全文化对上报意愿起到正向影响,其他影响因素起到负向影响。本研究为民航单位针对性提高员工上报意愿提供理论指导。     

Metal hydride fires and fire suppression agents

Most metal hydrides are pyrophoric and water-reactive. Summaries of metal hydride fire incidents are presented to illustrate ignition scenarios, threats to personnel and equipment, and fire suppression experiences. Met-L-X™, a sodium chloride-based, certified, Class D fire suppression agent, has successfully extinguished some metal hydride fires by coating the hydride and excluding air access. However, the still hot hydride is prone to re-ignition upon surface disturbance, such as may be necessary during disposal. Previously reported testing of various Class D agents and moist sand for sodium hydride fires is reviewed here along with certification and ad hoc testing of existing Class D agents and recent testing of a new candidate Class D agent. Hydride explosibility testing is also briefly summarized. Additional fire and explosibility tests, as well as suppression agent reactivity evaluations, are recommended.     

What will the car driver do? A video-based questionnaire study on cyclists' anticipation during safety-critical situations

Introduction: Many bicycle–car crashes are caused by the fact that the driver fails to give right of way to the cyclist. Although the car driver is to blame, the cyclist may have been able to prevent the crash by anticipating the safety-critical event and slowing-down. This study aimed to understand how accurate cyclists are in predicting a driver's right-of-way violation, which cues contribute to cyclists' predictions, and which factors contribute to their self-reported slowing-down behavior as a function of the temporal proximity to the conflict. Method: 1030 participants were presented with video clips of nine safety-critical intersection situations, with five different video freezing moments in a between-subjects design. After each video clip, participants completed a questionnaire to indicate what the car driver will do next, which bottom-up and top-down cues they think they used, as well as their intended slowing-down behavior and perceived risk. Results and conclusions: The results showed that participants' predictions of the driver's behavior develop over time, with more accurate predictions (i.e., reporting that the driver will not let the cyclist cross first) at later freezing moments. A regression analysis showed that perceived high speed and acceleration of the car were associated with correctly predicting that the driver will not let the cyclist cross first. Incorrect predictions were associated with believing that the car has a low speed or is decelerating, and with reporting that the cyclist has right of way. Correctly predicting that the driver will not let the cyclist cross first and perceived risk were significant predictors of intending to slow down in safety-critical intersection situations. Practical applications: Our findings add to the existing knowledge on cyclists' hazard anticipation and could be used for the development of training programs as well as for cycling support systems.     

Injury surveillance trends in career–technical education: New Jersey 1999–2018

Introduction: Adolescents engaging in school-sponsored work experiences may be at risk of injury due to factors such as inexperience. This article examines trends in 20 years of reported injuries among New Jersey (NJ) adolescents engaging in school-sponsored work experiences, and compares a transition from paper to online reporting format. Methods: New Jersey requires reporting of injuries occurring during school-sponsored work experiences to the NJ Department of Education. Injuries reported by NJ schools from 1999 to 2018 (n = 2,119) were examined; incidence rates for 2008 to 2018 (n = 743) were calculated using publicly available NJ Department of Education enrollment data for the denominator, including for specific groups of students: career and technical education; special healthcare needs. Results: A downward trend in reported injuries in NJ schools was observed. However, the year online reporting became required by code (2013), an increase of nearly 50% was seen from 2012 (59–89), followed by a decline in reported incidents 2014 to 2018 (mean = 65, range 76 down to 47). Injury rate trends over time paralleled those of reported incidents. Conclusions: This study suggested worker safety and public health benefits of improvements from State of NJ code required training programs and online injury surveillance report form. Practical Applications: One potential method to address the safety and health of adolescents engaging in work experiences is the use of online reporting forms, to aid in surveillance efforts, coupled with occupational safety and health training specifically geared toward teachers and administrators who both supervise young, relatively inexperienced and vulnerable workers and who make relatively frequent worksite visits. Incorporation of specific details of the instructions on the use of a reporting form into required trainings, in addition to providing a clear, accessible guidance manual online, could further help improve youth worker safety surveillance efforts.     

Global process safety incidents in the pharmaceutical industry

The objective of this research is to analyse global process safety incidents within the pharmaceutical industry in terms of their consequences and factors contributing to the incidents. There were 73 process safety incidents leading to 108 fatalities found between 1985 and 2019. Trends between the number of incidents, number of fatalities, location, and contributing factors were identified and summarized. The most reported fatalities occurred in 2018 & 2019. 83% of fatalities occurred in China and India. Explosions were associated with 71% of incidents, which resulted in 89% of fatalities. For most of the international incidents, incident investigations were not available and thus insufficient details were available to determine the causes. Contributing factors were available or estimated from available data for about half of the incidents, with the following most common: hazard awareness & identification; operating procedures; design; safeguards, controls & layers of protection; safety culture; and preventive maintenance. These findings can be used as a basis to improve process safety performance in the pharmaceutical industry.     

Lithium ion battery energy storage systems (BESS) hazards

There has been an increase in the development and deployment of battery energy storage systems (BESS) in recent years. In particular, BESS using lithium-ion batteries have been prevalent, which is mainly due to their power density, performance, and economical aspects. BESS have been increasingly used in residential, commercial, industrial, and utility applications for peak shaving or grid support. As the number of installed systems is increasing, the industry has also been observing more field failures that resulted in fires and explosions. Lithium-ion batteries contain flammable electrolytes, which can create unique hazards when the battery cell becomes compromised and enters thermal runaway. The initiating event is frequently a short circuit which may be a result of overcharging, overheating, or mechanical abuse. During the exothermic reaction process (i.e., thermal runaway), large amounts of flammable and potentially toxic battery gas will be generated. The released gas largely contains hydrogen, which is highly flammable under a wide range of conditions. This may create an explosive atmosphere in the battery room or storage container. As a result, a number of the recent incidents resulted in significant consequences highlighting the difficulties on how to safely deal with the hazard. This paper identifies fire and explosion hazards that exist in commercial/industrial BESS applications and presents mitigation measures. Common threats, barriers, and consequences are conceptually shown and how they would be identified in a hazard mitigation analysis (HMA). Mitigation measures that can be implemented to reduce the risk of a fire or an explosion are discussed. The presented information is intended to provide practical information to professionals and authorities in this fairly new industry to assure that prevention and mitigation strategies can be effectively implemented and that the regulatory requirement of the HMA can be met.     

Biotechnological research on the most dangerous pathogens: Challenges for risk governance and safety management

Biotechnological research on the deadliest pathogens has rapidly grown into a vast enterprise in the United States. With over $50 billion from federal agencies, thousands of projects are conducted at hundreds of university laboratories and other facilities in a national effort to gain the knowledge and methods for preventing the natural occurrence of pathogenic disease and protecting against bioterrorism. This paper describes this enterprise, defines several risk scenarios unrelated to terrorism which threaten lab workers and the public with lethal and contagious pathogenic disease, and evaluates the official policy framework for decision-making with regard to preventing and responding to the risk scenarios. It finds that the framework emphasizes physical security and secrecy to prevent terrorist exploitation of the enterprise, but fails to sufficiently address prevention of lab mishaps, accidental releases, and other incidents during the routine conduct of research which would expose workers and the public to the lethal pathogens. Nor does the framework effectively provide for the emergency response measures needed to prevent an accidental release of the more highly contagious pathogens from spiraling into a local or larger scale disease epidemic. These findings, supported by the growing number of near misses and small-scale incidents and lawsuits, point to major weaknesses in federal oversight and regulation, official disregard for siting criteria, inadequate self-regulation and management of lab safety practices, breakdowns in reporting systems, and obstacles to organizational learning and emergency response created by secrecy and security policies. Recommendations are made regarding these inadequacies of the federal framework and urge application of lessons learned from safety science experience with other hazardous technologies where increasing attention is being given to safety culture initiatives.     

我国民航实施安全管理体系(SMS)的思考

中国民航的快速发展需要一种系统的安全管理方法。本文总结了我国民航管理现状和所处的水平，分析了安全管理体系（SMS）方法的本质。同时笔者指出我国在SMS建设中一些人对SMS的建设重点、自愿报告系统等问题的认识上存在误区，最后提出了几点具有实践意义的操作方法帮助实施SMS建设。     

Safety and human factors considerations in control rooms of oil and gas pipeline systems: conceptual issues and practical observations.

All oil and gas pipeline systems are run by human operators (called controllers) who use computer-based workstations in control rooms to "control" pipelines. Several human factor elements could contribute to the lack of controller success in preventing or mitigating pipeline accidents/incidents. These elements exist in both the work environment and also in the computer system design/operation (such as data presentation and alarm configuration). Some work environment examples include shift hours, shift length, circadian rhythms, shift change-over processes, fatigue countermeasures, ergonomics factors, workplace distractions, and physical interaction with control system computers. The major objective of this paper is to demonstrate the critical effects of human and organizational factors and also to highlight the role of their interactions with automation (and automated devices) in the safe operation of complex, large-scale pipeline systems. A case study to demonstrate the critical role of human organizational factors in the control room of an oil and gas pipeline system is also presented.     

Justice for Bhopal! And No More Bhopals! Three decades of national and international campaigning

Dissatisfaction with the responses of the responsible corporation, Union Carbide, and the Indian government to Bhopal resulted in a campaign by national and international NGOs (non-governmental organisations) over the past three decades. While initially the Indian and international campaigns were separate, over time greater international cooperation took place. In the immediate aftermath of the disaster local NGOs prioritised health, justice and rehabilitation issues, while international NGOs used Bhopal to question chemical industry process and environmental safety in their own countries, as well as internationally. Indian NGOs called on international NGO resources to gain legitimacy for their campaign, to use NGOs as proxies and to extend the geographical scope of the campaign, while international NGOs used Bhopal as an example to advance NGOs analyses and policies. Over the period of the campaign, Indian NGOs became more sophisticated in their campaigning. The international campaign has increasingly become an online campaign, involved in an image or reputational war with Dow Chemical, which took over Union Carbide, while the original campaign issues of justice and reparations over the process safety disaster were joined by similar issues related to environmental safety of abandoned toxic waste.     

A methodology for enhancing the reliability of expert system applications in probabilistic risk assessment

In highly complex industries, capturing and employing expert systems is significantly important to an organization's success considering the advantages of knowledge-based systems. The two most important issues within the expert system applications in risk and reliability analysis are the acquisition of domain experts' professional knowledge and the reasoning and representation of the knowledge that might be expressed. The first issue can be correctly handled by employing a heterogeneous group of experts during the expert knowledge acquisition processes. The members of an expert panel regularly represent different experiences and knowledge. Subsequently, this diversity produces various sorts of information which may be known or unknown, accurate or inaccurate, and complete or incomplete based on its cross-functional and multidisciplinary nature. The second issue, as a promising tool for knowledge reasoning, still suffers from lack of deficiencies such as weight and certainty factor, and are insufficient to accurately represent complex rule-based expert systems. The outputs in current expert system applications in probabilistic risk assessment could not accurately represent the increasingly complex knowledge-based systems. The reason is the lack of certainty and self-assurance of experts when they are expressing their opinions. In this paper, a novel methodology is presented based on the concept of Z-numbers to overcome this issue. A case study in a high-tech process industry is provided in detail to demonstrate the application and feasibility of the proposed methodology.     

Self healing databases for predictive risk analytics in safety-critical systems

Assuring the quality, consistency and accuracy of safety data repositories is essential in safety-critical systems. In many systems, however, significant effort is required to identify, address, clean and repair data errors and inconsistencies, and to integrate safety data sets and repositories, particularly for risk analyses. Although some self healing and self repairing capabilities leveraging machine learning and predictive analyses have been employed to identify anomalies and monitor quality in structured safety-critical data sets, little attention has been focused on addressing shortcomings in heterogeneous—structured and unstructured—safety data sets, the focus of this work. The text mining and classification analysis employed in this research indicates that machine learning techniques can be employed to improve the accuracy and robustness of large-scale structured and unstructured database repositories, and to improve the effectiveness and efficiency of safety data repository maintenance. Hybrid machine learning approaches, leveraging machine learning, text mining and natural language processing, offer additional promise in future work.     

Lessons learned from recent incidents: Facility siting, atmospheric venting, and operator information systems

Recent incidents have focused attention on a number of technical and management systems that need to be addressed by industry. A multiple layer of protection approach is essential for the prevention of incidents and/or reduction of consequences. Safety culture and operational discipline are the overall embracing factors that influence the safety performance of a facility. However, as recent events have indicated, there are a number of technical and engineering issues that must also be developed and implemented appropriately. Some of these issues that could lead to incidents with catastrophic consequences include facility siting and atmospheric relief venting. Impact of operator information systems on the prevention of releases of hazardous materials from their containment is also another significant factor that should be given appropriate attention.

This paper describes these three topics based on the findings from recent incidents and historical data. Engineering standards, regulatory requirements, and industry practices are discussed for facility siting, atmospheric relief venting, and operator information systems. Finally, a summary of gaps and needs in technology, standards, and practices is presented.     

Measuring team trust: A critical and meta-analytical review

Team trust is gaining attention in research and practice due to its benefits for team performance, yet clarity about the intricacies of its measurement is needed. Therefore, we meta-analyzed 118 studies (N = 7,738) to untangle the role of measurement features by investigating the degree to which they influence the trust–performance relationship. Results showed that the trust–performance relationship is contingent upon time lag and source of measurement. Specifically, cross-sectional and single-source studies produced higher effect sizes than time-lagged and different-source studies. In contrast, the moderating roles of conceptualization–operationalization alignment and referent of trust measures were not supported. Post hoc analyses revealed that affective trust is more strongly related to global, versus specific team outcomes, and that mixed-referent items are particularly effective within intact teams, whereas the trust–performance relationship is constrained when direct consensus items are used within ad hoc teams. Furthermore, we provided a critical review that highlights the importance of composites, multilevel forces, and item content and wording. Finally, we clarified key gaps in the literature, calling for research where needed. This review serves as a bridge between conceptualization and measurement and lays the groundwork for advancing knowledge of team trust.