Safety management systems and safety culture in aircraft maintenance organisations

A self-regulatory model was proposed to examine how different organisations manage safety, with particular emphasis on the human and organisational aspects. The relationships of different aspects of safety culture and safety management systems were explored through the deployment of different research measures and methods. Studies of four aircraft maintenance organisations included analysis of documentation and qualitative interviews, surveys of safety climate and attitudes, expected response to incidents and compliance with task procedures. The model was effective in analysing the salient features of each organisation' s safety management system, though it underestimated the roles of planning and change. The data from management interviews, the incidents survey and safety climate survey exhibited a large measure of agreement in differentiating between the different safety management systems and safety climate of the four organisations. The measures of compliance with task procedures and safety attitudes did not differentiate between the four organisations (though one organisation did differ from the others in safety attitudes). This suggests a strong, relatively homogeneous professional sub-culture of aircraft technicians spanning the different organisations. Differences in safety attitudes and climate were found between occupational groups, though in the case of climate the differences between occupational groups were a function of the organisation, suggesting a differentiated notion of safety culture. The professional sub-culture of technicians is likely to mediate between the organisation' s safety management system and safety outcomes.     

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.     

Coding ATC incident data using HFACS: Inter-coder consensus

Reliability studies for coding contributing factors of incident reports in high hazard industries are rarely conducted and reported. Although the Human Factors Analysis and Classification System (HFACS) appears to have a larger number of such studies completed than most other systems doubt exists as the accuracy and comparability of results between studies due to aspects of methodology and reporting. This paper reports on a trial conducted on HFACS to determine its reliability in the context of military air traffic control (ATC). Two groups participated in the trial: one group comprised of specialists in the field of human factors and the other group comprised air traffic controllers. All participants were given standardised training via a self-paced workbook and then read 14 incident reports and coded the associated findings. The results show similarly low consensus for both groups of participants. Several reasons for the results are proposed associated with the HFACS model, the context within which incident reporting occurs in real organisations and the conduct of the studies.     

A study on the impact of management system certification on safety management

This study presents an empirical investigation of the influence of management system certification on the relationship between safety management and safety performance in major accident hazard chemical industry. The perceptions of employees about six important safety management practices and self-reported safety behaviour are measured with the help of a questionnaire survey administered in eight chemical companies in the state of Kerala in India. One thousand five hundred and sixty six workers participated in the survey with a response rate of 72%. The validity and reliability of the scales are found acceptable. Analysis of the data revealed that employees in companies with OHSAS 18001, ISO 9001 and no certification at all perceive different levels of the above safety variables in them and those in OHSAS 18001 organizations are significantly higher compared with the others. Step-wise regression analysis revealed that four out of six safety management practices predicted safety behaviour in OHSAS 18001 certified organization and three safety management practices were found to predict safety behaviour in the other two groups. But, safety rules and procedures (SR) emerged as a common predictor of safety behaviour in all the three models. This study emphasizes the need for OHSAS 18001 certification to reduce the accidents and thereby to reduce liability and improve productivity and safety and health of employees.     

引入“管理抵消因子”的作业条件危险评价方法

本文借鉴目前通行的作业条件危险评价方法，结合安全生产管理的实践，创新性地提出了一种新型的安全评价方法——引入“管理抵消因子”的“格雷厄姆——金尼法”。在发电企业的重大危险源评估中成功运用该方法，表明了该方法科学可行。     

Enhancing regional process safety management

As industrial operations expand, major incidents continue to affect people, damage facilities, and impact the environment. In the last 20 years, about 50% of these incidents occurred in facilities that had implemented some form of Process Safety Management (PSM) and 50% came about in smaller facilities that did not include such planning (Demichela et al., 2004). The objective of this article is to use PSM principles to create practical recommendations at the regional level, to complement those previously developed for singular facilities. This article compares Strathcona County Emergency Service (SCES) in Alberta with Technical Standards & Safety Authority (TSSA) in Ontario, with respect to safety, facility licensing, permit requirements, risk assessment procedures and land use planning aspects to determine PSM enhancements for SCES. Furthermore, for a better overview, two supplemental provincial organisations in Alberta, namely Alberta Boiler Safety Association (ABSA) and Safety Codes Council (SCC), were also considered. We proposed that SCES could develop more detailed facility-specific licensing procedures, auditing, and inspection. SCES could also provide details of accredited organisations that carry out inspections and audits on their behalf. When reviewing the quantitative risk assessment processes for SCES and TSSA, we recommend that SCES should update their probability data sources used in their cumulative risk assessment study. Based on the authors’ experience and gathered data, the use of additional facility practices such as safety management system, internal audits, and checklists can enhance incident prevention.     

Can focus on safety culture become an excuse for not rethinking design of technology?

Two generic organisational contexts associated with technological designs in relation to safety culture are discussed: (1) operating organisations using existing technologies, and (2) design organisations as producers of technologies. It is argued that the concept of safety culture, if misused, may lead to the adoption of non-effective change strategies in the operational context. On the other hand, it is also argued that design organisations should invest more attention to issues commonly subsumed under the concept of safety culture. In this case, however, the concept of safety culture has to be adapted to fit the demands facing design organisations. Issues of morality and their association with the safety culture concept will be discussed. It is suggested that a stronger focus on understanding innovation and safety together should nourish future research about culture’s influence on design and safety.     

Small businesses and OH&S advisors

Traditionally occupational health and safety (OH&S) enquiry has viewed the world of work as if it comprised of blue-collar male workers employed on a full-time basis in large organisations. However, to continue to analyze workplace health and safety within the narrow confines of unionized labour situated in large organisations is to ignore the health and safety in non-unionised small businesses. Therefore, this paper challenges existing OH&S research by investigating the compliance experiences of small businesses. The paper also demonstrates that small business employers are becoming increasingly reliant on their accountant to provide a range of compliance advisory services, including OH&S. However, the notion that small accounting firms act as ‘intermediary advisors’ between the OH&S regulatory agencies and the small business sector may influence the way in which regulatory agencies achieve OH&S compliance in small workplaces. Finally, the study reinforces the need for a more flexible approach to OH&S in the small business sector.     

Systematic incorporation of inherent safety in hazardous chemicals supply chain optimization

Increasing globalization has made many chemical supply chains large, interdependent and complex. Process incidents often affect the reliability of a supply chain and can cause large disruptions at different segments of the industry. We propose an optimization-based framework that systematically takes into account the trade-offs between process safety and supply chain economics for decision-making. We quantify the hazard at various supply chain echelons in the form of a safety index that takes both fire and toxic hazards into account. A mixed-integer nonlinear programming (MINLP)-based model is developed to either maximize profit for specified hazard limits, or to minimize hazard in a supply chain with multiple production plants, technological options, warehouses and distribution nodes. The MINLP model is used to generate trade-off optimal solutions for various toxic and fire hazard limits. The framework is demonstrated by applying it to an end-to-end ammonia supply chain case study which resulted in several non-intuitive observations regarding hazardous supply chain design and optimization.     

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.     

A framework for learning from incidents in the workplace

Learning from Incidents (LFI) in the workplace has been gaining increasing importance in the Health, Safety and Environment context. Although organisations adopt a variety of LFI initiatives, it is often unclear what learning approaches are the most appropriate and the most effective for different types of incidents across a range of contexts. The aim of the paper is to surface factors that are important for effective Learning from Incidents (LFI). The paper builds on a conceptual framework for learning from incidents, developed through an earlier study. This conceptual framework was validated through empirical data collected at two multinational corporations in the energy sector. From this data a refined framework for learning from incidents was devised with five factors important for LFI: participants of learning, type of incidents, learning process, type of knowledge and learning context. This framework can be used as an evaluation tool and as a guidance tool to develop holistic, organisational learning approaches.     

Comparing the usability and reliability of a generic and a domain-specific medical error taxonomy

Medical error taxonomies are used to report and analyse patient safety incidents. Medical error taxonomies can be generic or domain-specific. In comparing generic and domain-specific medical error taxonomies, the literature compares the information both type of taxonomies classify. There is little evidence the taxonomies have been compared in terms of usability and reliability. Twenty nurses and 21 pharmacists participated in a study comparing the usability and reliability of a generic medical error taxonomy and a medication error taxonomy. The medical error taxonomies utilized were the Patient Safety Event Taxonomy and the NCC MERP Taxonomy of Medication Error. The study found no significant difference in the usability ratings of both taxonomies. The taxonomies required different amount of time to classify patient safety incidents and had significantly different reliability levels. The reliability of the NCC MERP Taxonomy of Medication Error was significantly different when used by nurses and pharmacists. The taxonomy was also preferred by the majority of participants. Some recommendations are made about the design of future medical error taxonomies.     

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.     

硝基苯精馏再沸器安全分析与评估

为了明确硝基苯精馏再沸器装置爆炸事故发生的原因,有针对性的采取预防措施,综合运用英国帝国化学工业公司的IC I蒙德评价法和事故树分析（FTA）法对精馏再沸器进行安全分析研究,确定了该装置生产过程中的物料物质系数,计算相关的物质危险性、工艺危险性和毒性指数,经过安全措施补偿系数修正后,得出了硝基苯精馏再沸器总危险性系数和危险等级;定性地分析了各危险因素的大小;定量地得出装置的危险程度,并提出了安全措施。结果表明,该装置的危险等级属中等,高温下漏入空气、阀门失效和法兰密封不严是导致该事故的3个最主要的原因,因此,应从以上几方面采取措施,加强安全生产管理。控制精馏再沸器的加热温度,防止局部积累热量,从而降低危险等级,确保安全生产。     

Does the potential safety risk affect whether particular construction hazards are recognized or not?

Introduction: Evidence from the global construction industry suggests that an unacceptable number of safety hazards remain unrecognized in construction workplaces. Unfortunately, there isn’t a sufficient understanding of why particular safety hazards remain unrecognized. Such an understanding is important to address the issue of poor hazard recognition and develop remedial interventions. A recent exploratory effort provided anecdotal evidence that workers often fail to recognize safety hazards that are expected to impose relatively lower levels of safety risk. In other words, the research demonstrated that the underlying risk imposed by a safety hazard can affect whether a hazard will be recognized or not. Method: The presented research focused on empirically testing this preliminary finding. More specifically, the study tested the proposition that Construction workers are more likely to recognize safety hazards that impose higher levels of safety risk than those that impose relatively lower levels of safety risk. The research goals were accomplished through a number of steps. First, a set of 16 construction case images depicting a variety of construction operations that included a number of known safety hazards was presented to a panel of four construction safety experts. The experts were tasked with examining each of the known safety hazards and providing a rating of the relative safety risk that the individual hazards impose. Having obtained an estimate of the underlying safety risk, a hazard recognition activity was administered to 287 workers recruited from 57 construction workplaces in the United States. The hazard recognition activity involved the examination of a random sample of two construction case images that were previously examined by the expert panel and reporting relevant safety hazards. Results: The results of the study provided support for the proposition that workers are more likely to recognize hazards that impose relatively higher levels of safety risk. Practical Applications: The findings of the study can be leveraged to improve existing hazard recognition methods and develop more robust interventions to address the issue of poor hazard recognition levels.     

Measuring safety climate in aviation: A review and recommendations for the future

This paper reviews 23 studies that have examined safety climate within commercial and military aviation. The safety climate factors identified in the aviation safety climate questionnaires were found to be consistent with the literature examining safety climate in non-aviation high reliability organizations. Therefore, it was concluded that the aviation safety climate tools had some construct validity (the extent to which the questionnaire measures what it is intended to measure). However, the majority of the studies made no attempt to establish the discriminate validity (the ability of the tool to differentiate between organizations or personnel with different levels of safety performance) of the tools. It is recommended that rather than constructing more aviation safety climate questionnaires, researchers should focus on establishing the construct and discriminate validity of existing measures by correlating safety climate with other metrics of safety performance. It is recognized that the accident rate in commercial aviation is too low to provide a sufficiently sensitive measure of safety performance. However, there are other measures of safety performance, collected as part of a company’s Aviation Safety Action Program or Flight Operational Quality Assurance, which could be used to assess the discriminate validity of an aviation safety climate tool.     

A safety culture maturity model for petrochemical companies in Brazil

A framework to measure safety culture maturity in the Brazilian oil and gas companies was formulated based on the model of Hudson (2001). Following a review of the safety culture literature, a questionnaire was designed to measure five aspects of organisational safety indicative of five levels of cultural maturity. The questionnaire was completed by the safety managers of 23 petrochemical companies based in Camacari, Bahia, Brazil and they were interviewed one month later. The reliability of the questionnaire was tested by asking the same questions in an interview and comparing the results (alternate forms reliability). The correlation coefficients between the questionnaire and interview scores on each dimension ranged from r = 0.7 to 0.9, demonstrating good reliability of the measures used. The research findings demonstrated that the 23 companies studied showed characteristics of different levels of safety culture maturity. Most scores were at the level of proactive. The model of Hudson (2001) and the revised framework and questionnaire were found to be practical to use, making it possible to identify levels of safety culture maturity in the context of the Brazilian petrochemical industry.     

A violent,episodic vapour cloud explosion assessment: Deflagration-to-detonation transition

A large vapour cloud explosion (VCE) followed by a fire is one of the most dangerous and high consequence events that can occur in petrochemical facilities. The current process of safety practice in the industry in VCE assessment is to assume that all VCEs are deflagration. This assumption has been considered for nearly three decades. In recent years, major fire and VCE incidents in fuel storage depots gained considerable attention in extreme high explosion overpressure due to the transition from Deflagration to Detonation (DDT). Though the possibility of DDTs is lower than deflagrations, they have been identified in some of the most recent large-scale VCE incidents, including Buncefield (UK), 2005, San Juan explosion (US), 2009, and IOCL Jaipur (India), 2009 event. Such an incident established the need to understand not only VCE but also the importance of avoiding the escalation of minor incidents into much more devastating consequences.Despite decades of research, understanding of the fundamental physical mechanisms and governing factors of deflagration-to detonation transition (DDT) transition remains mostly elusive. An extreme multi-scale, multi-physics nature of this process uncertainly makes DDT one of the “Grand Challenge” problems of typical physics, and any significant developments toward its assured insistence would require revolutionary step forward in experiments, theory, and numerical modelling. Under certain circumstances, nevertheless, it is possible for DDT to occur, and this can be followed by a propagating detonation that quickly consumes the remaining detonable cloud. In a detonable cloud, a detonation creates the worst accident that can happen. Because detonation overpressures are much higher than those in a deflagration and continue through the entire detonable cloud, the damage from a DDT event is more severe. The consideration of detonation in hazard and risk assessment would identify new escalation potentials and recognize critical buildings impacted. This knowledge will allow more effective management of this hazard.The main conclusion from this paper is that detonations did occur in Jaipur accident at least part of the VCE accidents. The vapour cloud explosion could not have been caused by a deflagration alone, given the widespread occurrence of high overpressures and directional indicators in open uncongested areas containing the cloud. Additionally, the major incident has left many safety issues behind, which must be repeatedly addressed. It reveals that adequate safety measures were either underestimated or not accounted for seriously. This article highlights the aftermath of the IOCL Jaipur incident and addresses challenges put forward by it.     

Technical note on the contribution of sociotechnical factors to accidents notified to MARS

Not least due to the new `Seveso II Directive', Safety Management Systems (SMS) have become a hot topic in the `safety business'. To reveal in a structured way how organisations manage safety at their plants, classification schemes can be applied to identify plant-specific precautions on different hierarchical levels, e.g. from `top level' equipment reliability to `bottom level' safety climate. In this paper, such a model is used to classify the accidents reported to the European Commission's Major Accident Reporting System (MARS) according to the levels on which failures resulting in actual accidents did occur, and to cross-compare the levels of causation with the overall `severity' of the accidents. It is analytically shown that ∼66% of the accidents are caused by latent SMS failures, and that especially those accidents which are caused by failures in the `deepest layers of latency' have significantly higher `severities' than accidents caused by more `immediate' failures. In other words, it is quite likely that the deeper the underlying causes of an accident, the more `severe' its consequences. Implementing SMS is thus worth the effort.