Domino effect in process-industry accidents - An inventory of past events and identification of some patterns

The paper presents an inventory, perhaps the most comprehensive till date, of the major process-industry accidents involving ‘domino effect’. The inventory includes, among other relevant information, the sequence of accidents that had occurred in each domino episode. The information has been analyzed to identify several patterns which may be useful in further work on understanding domino effect and reducing the probability of its occurrence in future. A concept of ‘local domino effect’ has been introduced.     

Overview of the relationship between organizational and workplace factors and injury rates

This paper summarizes data from ten studies examining the relationship between organizational and workplace factors and injury rates. The studies were identified from a systematic literature search, as well as from other sources, and were included if they reported comparisons among at least 20 workplaces. Factors that were examined in at least two studies were identified. Their relationship with injury rates was determined. It was not possible to make quantitative comparisons between studies. We looked for ‘consistency’ or ‘contradiction’ in the relationships. Among the variables ‘consistency’ associated with lower injury rates were: empowerment of the workforce (in general matters); delegation of safety activities; and an active role (in health and safety) of top management. Among the ‘contradictory’ variables were the level and use of discipline for safety violations; and several others that were contradictory only in subgroups of the same study. We discuss the limitations of synthesizing results from the diverse studies.     

Risk assessment in support to land-use planning in Europe: Towards more consistent decisions?

Recognising the importance of establishing appropriate separation distances between hazardous installations and vulnerable residential areas for mitigating the effects of industrial accidents, the European legislation for the control of major accident hazards - the so-called Seveso II Directive - calls for procedures ensuring that technical advice is taken systematically into account for land-use planning (LUP) purposes. Due to historical, administrative, cultural and other reasons, these European Union’s Member States which have consolidated procedures for addressing this issue, have employed different approaches, methods and criteria, with a potential for great divergence in the resulting land-use planning decisions. In order to address this situation and to increase consistency and ‘defendability’ of land-use planning decisions in the EU, a European Working Group has been established and is operating under the coordination of the European Commission’s Joint Research Centre (JRC). This Group, consisting of experts from the EU Member States, the industry and the academia, is trying to understand the different approaches and their implications to LUP decision-making, to develop guidelines in support to these decisions and to examine data sources and tools for consistent application of risk assessment in support to LUP. This paper presents the activities of the Group, reviews the situation with respect to LUP in Europe and discusses whether a direction towards more consistent LUP decisions is being followed in Europe.     

The effectiveness of U.S. OSHA process safety management inspection – A preliminary quantitative evaluation

This study attempted to evaluate the inspection effectiveness of the U.S. OSHA process safety management (PSM) standard using statistical correlation test. A total of 6578 citations of past 1277 OSHA PSM inspections from 1992 to 2006 were quantitatively compared with the findings of the U.S. Chemical Safety and Hazard Investigation Board (CSB) investigations on root and contributing causes of 19 major chemical accidents. Nonparametric Spearman's coefficient of rank correlation tests showed a moderately strong agreement between OSHA PSM inspection citations and CSB findings at p < .01 significant level, and the degree of agreement increased with time. These results suggested that past OSHA PSM inspections had cited the problems that were the accident root causes, and the effectiveness of PSM citations has been improved as more inspections were conducted since the standard promulgation. However, factors such as standard coverage, inspection frequency, inspection resources allocation, and inspection strategy, were critical for effective PSM standard enforcement and implementation. Future studies should include more aspects of PSM citations and CSB accident investigation data for better evaluation of inspection effectiveness. The results may be valuable to the PSM enforcement policy makers.     

Time series analysis of coal mine accident experience

This study investigates several forecasting techniques that can be useful to mine safety managers for studying mine accident rate behavior. Three time series models were studied for extrapolation of accident rates. These models are applied to historical accident incidence data from a coal mine. Further, a method is presented for evaluating the three models for the selection of an appropriate model. For this particular mine application, it is concluded that the more complex Box-Jenkins ARMA model as well as first order autoregressive model do not give better results than the simple exponential smoothing model. However, when the random variations or autocorrelations in the accident experience rates between periods are different, the models may predict differently. As such, specific models must be developed for each mine on the basis of statistical analysis of the mine accident experience data over time. Moreover, the importance of incorporating human judgement to interpret the results of statistical forecasting cannot be overemphasized. Integration of policy or operating changes, which may impact mine safety performance, with statistical forecasting techniques is essential to arrive at a realistic prediction of future performance.     

Walking when intoxicated: An investigation of the factors which influence individuals’ drink walking intentions

Annually, in Australia, 10-15% of all road-related fatalities involve pedestrians. Of those pedestrians fatally injured, approximately 45% were walking while intoxicated or ‘drink walking’. Drink walking is increasing in prevalence and younger persons may be especially prone to engage in this behaviour and, thus, are at heightened risk of being injured or killed. Presently, limited research is available regarding the factors which influence individuals to drink walk. This study explored young people’s (17-25 years) intentions to drink walk, using an extended Theory of Planned Behaviour (TPB). Participants (N = 215), completed a self-report questionnaire which assessed the standard TPB constructs (attitude, subjective norm, perceived behavioural control) as well as the extended constructs of risk perception, anticipated regret, and past behaviour. It was hypothesised that the standard TPB constructs would significantly predict individuals’ reported intentions to drink walk and that the additional constructs would predict intentions over and above the TPB constructs. The TPB variables significantly predicted 63.2% of the variance in individuals’ reported intentions to drink walk, and the additional variables, combined, explained a further 6.1% of the variance. Of the additional constructs, anticipated regret and past behaviour, but not risk perception, were significant predictors of drink walking intentions. As one of the first studies to provide a theoretically-based investigation of factors influencing individuals’ drink walking intentions, the current study’s findings have potentially significant implications for understanding young people’s decisions to drink walk and the design of future countermeasures to ultimately reduce this behaviour.     

Accidents in the chemical industry: are they foreseeable?

‘Accidents recur,’ which is what Kletz [Kletz T. (1993). Lessons from disasters, how organisations have no memory and accidents recur. UK: Institution of Chemical Engineers] wrote in 1993. Indeed, despite all measures taken accidents may re-occur, but ‘disruptions’ in a process reoccur much more frequently. If a disruption occurs it may lead to an accident. If the same disruption reoccurs it is certainly suspect and should be considered as a potential precursor. In this paper, we concentrate on these disruptions and we will define them as precursors if they recur. Organizations somehow lack the ability to control such recurring disruptions that may escalate into serious accidents under certain circumstances. The presence of such precursors long before the occurrence of an accident raises doubts about how well organizations control safety.In this paper, the control mechanism inside organizations is examined, by means of several accident investigations. It will be shown that not only accidents recur, but also that disruptions recur in a period preceding the actual accident. The recurrence of these disruptions implies that the corresponding organizational control mechanism must be failing. Often, alternative circumstances prompt the escalation of such precursors and lead to actual accidents. It is demonstrated that the use of detailed accident information is of great importance for companies that are actually willing to prevent accidents through the elimination of disruptions preceding accidents.     

Challenges and proposals for managing major accident risk through the planning process

Major accidents are characterized by complex causal patterns with many factors influencing the occurrence of such accidents. The causes can be found not just in the execution of the work, but also in the preparations and planning before performing the work. In this paper, we have identified a set of challenges related to planning that may influence major accident risk. The basis is theoretical and partly empirical. The theoretical part is from a study of major accident theories. The empirical part includes studies of investigation reports, interviews and a workshop. The challenges identified can be grouped into four main topics including inadequate plan, inadequate planning, inadequate shared overview and understanding and late risk identification. The challenges have subsequently been addressed through a set of proposed improvements, which are aimed at improving the planning process to better manage major accident risk.     

Project safety as a sustainable competitive advantage

Introduction: To be consistently profitable, a construction company must complete projects in scope, on schedule, and on budget. At the same time, the nature of the often high-risk work performed by construction companies can result in high accident rates. Clients and other stakeholders are placing increasing pressure on companies to decrease those accident rates. Clients routinely demand copies of safety plans and evidence of past results at the “pre-qualification” or “request for proposal” stages of the procurement process. Are high accident rates and the associated costs just a part of business? Findings: Companies that deliver on scope, schedule, and budget have a competitive advantage. Is it possible for projects with low accident rates to use it as a competitive advantage? Is the value added by safety just a temporary or parity issue, or does a successful safety program offer significant advantage to the company and the client? Impact on Industry: This article concludes that in the case of a high-risk industry, such as the construction industry, an organization with a successful safety program can promote safety performance as a sustainable competitive advantage. It is a choice the company can make.     

Multilevel learning from accidents – Case studies in transport

Substantial efforts have been devoted to accident investigations, but do we gain a reasonable benefit from these efforts? The current study explores multilevel (individual, company, sector/trade, authorities) learning from major accidents and serious incidents. Specifically, this involves identifying a set of learning criteria, i.e. factors or indicators that potentially support and contribute to multilevel learning processes. Identifying such criteria is based on: (i) the accident investigation process, (ii) the follow-up efforts, and (iii) contextual aspects. Three Norwegian accident investigations in transportation (aviation, marine, rail) represent the empirical foundation for the study. Learning criteria were derived by both document analyses from the accidents (e.g. investigation reports) and literature reviews on organizational learning. These were the basis for a workshop regarding learning from accidents, with participants from the aviation, marine, and rail sector. Key results from this workshop are presented and discussed. The study concludes by presenting a set of criteria for learning from accidents.     

重大事故责任罪之我见

对完善重大责任事故罪立法的专题研究,着重研究重大责任事故罪的犯罪主体、重大责任事故罪刑种、重大责任事故危险犯等三方面问题。     

The successes and challenges of implementing high reliability principles: A case study of a UK oil refinery

Research conducted on organisations that are able to sustain excellent safety records over long time periods suggests that there are a number of practices that organisations can adopt to achieve high levels of reliability and safety. These practices are often discussed in the context of major incidents to highlight the safety standards that high hazard organisations should try to emulate. However, previous research has predominantly focused on non-profit organisations, and comparatively little research has examined whether high reliability practices may be meaningfully applied to commercial contexts. This paper addresses this gap by using a qualitative approach to explore the types of reliability-enhancing practices implemented in a UK-based oil refinery in its attempt to achieve its ethos of ‘safe and reliable operations’. The findings illustrate the successful application of reliability-enhancing practices in several domains, including: hazard identification and control; emergency preparedness and collection; and analysis of incidents and near misses. Management commitment to safety emerged as an important factor underpinning the successful implementation of reliability-enhancing practices, highlighting its potential significance in the context of commercial organisations. However, promoting an open reporting culture and maintaining high levels of management visibility may be some of the challenges encountered by organisations striving to implement reliability-enhancing practices.     

Behavior and lifestyle characteristics of male Kuwaiti drivers

Introduction: The high traffic accident risk among young drivers is a well-known and well-documented fact in most countries. Lifestyle has proven to affect driving behavior as well as accident risk. This study covers the lifestyle component of the problems related to young male Kuwaiti drivers’ accident risk. Methods: The purpose of the study is to measure the relationship between lifestyle and accident risk. Lifestyle is measured through a questionnaire, where 302 male Kuwaiti drivers (mean age = 28 years; range 25-35 years) answer 39 questions related to behavioral and social factors, road conditions, police enforcement, and life satisfaction. They also report their involvement in accidents and traffic violations. Results: The questionnaire's validity and reliability (Cronbach's alpha = 0.7) were achieved. Principal component analysis reduced the 39 items on the questionnaire to 5 factors. Inadequate police enforcement is strongly correlated (r = 0.862) to accident risk and traffic violations and is thus considered the best predictor of traffic accidents in Kuwait. Impact on Industry: As driving-related incidents (on-the-job and off-the-job) are a significant source of fatalities and lost-work-days, the study points to the importance of considering cultural factors in the design of comprehensive safety programs for industry.     

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.     

Investigation of key factors for accident severity at railroad grade crossings by using a logit model

Although several studies have used logit or probit models and their variants to fit data of accident severity on roadway segments, few have investigated accident severity at a railroad grade crossing (RGC). Compared to accident risk analysis in terms of accident frequency and severity of a highway system, investigation of the factors contributing to traffic accidents at an RGC may be more complicated because of additional highway–railway interactions. Because the proportional odds assumption was violated while fitting cumulative logit modeled by the proportional odds models with stepwise variable selection to ordinal accident severity data collected at 592 RGCs in Taiwan as suggested by Strokes et al. [Strokes, M.E., Davis, C.S., Koch, G.G., 2000. Categorical Data Analysis Using the SAS System, second ed. SAS Institute, Inc., Cary, NC, p. 249], a generalized logit model with stepwise variable selection was used instead to identify explanatory variables (factors or covariates) that were significantly associated with the severity of collisions. Hence, the fitted model was used to predict the level of accident severity, given a set of values in the explanatory variables. Number of daily trains, highway separation, number of daily trucks, obstacle detection device, and approaching crossing markings significantly affected levels of accident severity at an RGC (p-value = 0.0009, 0.0008, 0.0112, 0.0017, and 0.0003, respectively). Finally, marginal effect analysis on the number of daily trains and law enforcement camera was conducted to evaluate the effect of the number of daily trains and presence of a law enforcement camera on the potential accident severity.     

Event investigations at nuclear power plants in Sweden: Reflections about a method and some associated practices

The MTO-E method for event investigation is described in the light of almost 20 years of usage in the Swedish nuclear industry. Various problems are addressed in the context of the method, e.g. accident models, causality, the use of the barrier concept, the meaning of safety culture, and the process of going from problem identification to problem solving. It is argued that future applications of in-depth investigations should focus more on (innovative) methods when suggesting remedial actions as a consequence of information derived from event investigations.     

The self-defensive attribution hypothesis in the work environment: Co-workers’ perspectives

The study explored the possible influences of situational, personal and non-relevant perception on causality attributions and responsibility assignment in Ghana’s work environment. Ghanaian industrial workers (co-workers) who were witnesses to industrial accidents (n = 117) assigned causality for the mishap and their responses were compared. Analyses were based on the co-workers’ responses to open-ended questions. Three categories of co-workers were identified and labelled as situationally relevant (n = 34), personally relevant (n = 43) and non-relevant co-workers (n = 40). The results showed that co-workers (witnesses) who had some perception of situational and or personal relevance with the accident victims attributed less responsibility to the accident victims than did their counterparts who had no perception of relevance. This observation, like other motivated attributional distortions, seems to reflect a tendency towards self-protection from the three categories of co-workers. It confirms the self-defensive attribution hypothesis in causal attributions about accidents in the work environment.     

A comparison of safety practices used by managers of high and low accident rate postal delivery offices

This study compared safety practices of managers (supervisors) of high and low accident rate postal delivery offices, particularly with respect to slip, trip and fall accidents. Identification of ‘desirable’ management safety activities was achieved using findings from previous research, manager interviews, and a focus group with Royal Mail senior safety personnel. Interviews were then conducted with 20 Delivery Office Managers (DOMs), drawn equally from matched high and low accident rate offices, to examine use of safety practices. DOMs from low accident rate offices appeared to have improved performance with respect to quality of safety communication, dealing with hazards reported on delivery walks, and accident investigation and remedial action. Efforts to reduce risks from severe weather were limited in both high and low accident offices, seemingly influenced by the organisation's emphasis on maintaining quality of service. Confusion existed regarding footwear entitlements of employees, and none of the sample of DOMs encouraged use of alternative methods of delivery to manual pouch carriage. A model is described illustrating the hierarchy of factors that may affect occurrence of slip, trip and fall accidents within a large organisation. The model indicates that supervisors' impact arises both from their attitudes and their actions. The study supports the finding of previous cross-organisational investigations that supervisors have an important influence on workplace safety.     

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.