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.     

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.     

The legacy of Bhopal: The impact over the last 20 years and future direction

Chemical process safety was not a major public concern prior to 1984. As far as chemical hazards were concerned, public fears focused on disease (cancer) and environmental degradation. Even a series of major process incident tragedies did not translate into widespread public concerns about major incidents in chemical plants that might disastrously affect the public. This situation changed completely after the December 1984 disaster at the Union Carbide plant in Bhopal. Not only was the public's confidence in the chemical industry shaken, the chemical industry itself questioned whether its provisions for protection against major incidents were adequate.

The recognition of the need for technical advances and implementation of management systems led to a number of initiatives by various stakeholders throughout the world. Governments and local authorities throughout the world initiated regulatory regimes. Has all that has resulted from the legacy of Bhopal reduced the frequency and severity of incidents? How can we answer this question? As we move into more and more globalization and other complexities what are the challenges we must address? According to the authors, some of these challenges are widespread dissemination and sharing of lessons learned, risk migration because of globalization, changing workforce, and breakthroughs in emerging areas in process safety.     

Learning from incidents – A method for assessing the effectiveness of the learning cycle

This paper describes a method for assessing the effectiveness in the steps of the learning cycle: the 1st loop with reporting – analysis – decision – implementation – follow-up, and the 2nd loop on an aggregated basis. For each step, the dimensions considered the most relevant for the learning process (scope, quality, timing and information distribution) and for each dimension the most relevant aspects (e.g. completeness and detail) were defined. A method for a semi-quantitative assessment of the effectiveness of the learning cycle was developed using these dimensions and aspects and scales for rating. The method will give clear indications of areas for improvement when applied. The results of the method can also be used for correlation with other safety parameters, e.g. results from safety audits and safety climate inquiries. The method is intended to be used on a sample of the broad range of incidents normally seen in process industry companies. The method was tested on a two-year incident reporting material from six companies from various types of process industries. It was found that the method and the tools worked very well in practice. The results gave interesting insights into the effectiveness of learning from the incidents.     

Modeling attitudes and perceptions as predictors for changing safety margins during organizational change

This study describes the relations between different dimensions of leadership commitment, safety climate and attitudes toward change, and how these affect employee perceptions of safety during organizational change in a high risk environment. We collected data from a European national air navigation services provider during a volatile 3-year corporatization process that ended in the sudden collapse of a deliberate change implementation project. Surprisingly, despite visible signs of internal and external stress caused by the volatile and disruptive change process, we did not observe any change in the traditional safety metrics of incident and accident reporting during the study. The study is based on a large survey (n = 422) of individual attitudes and perceptions of safety climate, perception of leadership commitment to safety, attitudes to organizational change, and perception of safety. The data support the claim that perception of safety at least, in part, depends on individual perceptions of the leadership’s commitment to safety, and the safety climate in place at a given point in time. The model shows how employee perceptions of the leadership’s commitment to safety and safety climate are related to both attitudes toward change, and to perceived safety.     

The relationship between employees' perceptions of safety and organizational culture

PROBLEM: With limited resources to help reduce occupational injuries, companies struggle with how to best focus these resources to achieve the greatest reduction in injuries for the optimal cost. Safety culture has been identified as a critical factor that sets the tone for importance of safety within an organization. METHOD: An employee safety perception survey was conducted, and injury data were collected over a 45-month period from a large ready-mix concrete producer located in the southwest region of the United States. RESULTS: The results of this preliminary study suggest that the reductions in injuries experienced at the company locations was strongly impacted by the positive employee perceptions on several key factors. Management's commitment to safety was the factor with the greatest positive perception by employees taking the survey. DISCUSSION: This study was set up as a pilot project and did not unitize an experimental design. That weakness reduces the strength of these findings but adds to the importance of expanding the pilot project with an appropriate experimental design. SUMMARY: Management leadership has been identified, along with several other factors, to influence employee perceptions of the safety management system. Those perceptions, in turn, appear to influence employee decisions that relate to at-risk behaviors and decisions on the job. IMPACT ON INDUSTRY: The results suggest that employee perceptions of the safety system are related to management's commitment to safety, which, in turn, appear to be related to injury rates. Management should focus on how to best leverage these key factors to more positively impact injury rates within their companies.     

境外企业社会安全事件调查分析方法研究

针对我国境外企业在社会安全方面所面临的严峻形势,对境外企业社会安全事件的调查分析方法进行研究.通过对境外中资企业社会安全事件的分类、分级,事件报告和调查的程序,事件统计分析方法等方面的研究,提出境外社会安全事件的分类、分级的标准和原则,境外社会安全事件报告和调查的程序及主要注意事项及统计分析的建议,设计了境外中资企业社会安全事件管理的基本框架,从而加强社会安全事件的调查和统计分析,为科学统计此类事件造成的损失提供依据.     

Harnessing database resources for understanding the profile of chemical process industry incidents

Analyzing historical databases can provide valuable information on the incident occurrences and their consequences for assessing the safety of the chemical process industry. In this study, the RMP and HSEES databases were utilized to understand the patterns and the factors influencing chemical process industry incidents. Frequency exceedance curves were generated by utilizing the different incident consequences from the databases to understand the profile of societal loss from reported incidents. Understanding the statistics and trends of the historical incidents could serve as important lagging indicators in order to assess the probable proximity to major consequences from the low-probability/high-consequence incidents. To this regard, the safety pyramids were also generated to better understand the relationship between the different consequences of the reported incidents. Furthermore, the safety pyramids were analyzed in comparison with the traditional safety pyramid proposed by Heinrich to understand the US process industry incident occurrence trends.     

Software tools to support incident reporting in safety-critical systems

Incident reporting systems are playing an increasingly important role in the development and maintenance of safety-critical applications. The perceived success of the FAA's Aviation Safety Reporting System (ASRS) and the FDA's MedWatch has led to the establishment of similar national and international schemes. These enable individuals and groups to report their safety concerns in a confidential or anonymous manner. Unfortunately, many of these systems are becoming victims of their own success. The ASRS and MedWatch have both now received over 500,000 submissions. In consequence, the administrators of incident reporting systems increasingly rely upon software tools to support the administration of their systems. In the past, these systems have relied upon ad hoc applications of conventional database technology. However, there are several reasons why this technology is inadequate for many large-scale reporting schemes. In particular, the problems of query formation often result in poor precision and recall. This, in turn, has profound implications for safety-critical applications. Users may fail to identify similar incidents within national or international collections. These ad hoc approaches also neglect the opportunities provided by recent developments in computer assisted interviewing and in the monitoring of retrieval activities to build models of user behavior. These techniques offer a number of potential benefits. For instance, it is possible to automatically detect potential biases in the way that investigators analyze particular incidents.     

Cultural influences on risks and risk management: six case studies

Ever since the accident at the Three Mile Island nuclear power plant on 28 March 1979, the term ‘safety culture’ has been a hot topic for both researchers and organisations. Both the content and causes of a poor safety culture have been the focus of numerous research projects, but also its consequences on an organisation's safety performance and the way organisations should be ‘designed’ to facilitate a ‘good’ safety culture. Since others in this issue focus on the content and causes of safety culture, this article focuses on its consequences from two different but inter-related angles. In the first place, the cultural influences on incident causation are considered. In the second place, the cultural influences on risk management, or specifically incident reporting and analysis, are considered. Both angles are supported by empirical incident data collected in the Dutch steel industry and the medical domain. To collect this data, a risk management approach called PRISMA was used. Further, cultural differences between the domains investigated are highlighted and discussed.     

Performance evaluation of integrated resilience engineering factors by data envelopment analysis: The case of a petrochemical plant

Petrochemical units are potentially prone to incidents that have catastrophic consequences such as explosion, leakage of toxic materials, and the stoppage of the production process. Resilience engineering (RE) is a new method that can control incidents and limit their consequences. It includes top-level commitment, reporting culture, learning, awareness, preparedness, and flexibility. However, this study introduces a new concept of RE (referred to as integrated RE or IRE) which includes the above factors in addition to self-organization, teamwork, redundancy and fault-tolerant. This study evaluates performance of IRE in a petrochemical plant through considering the obtained data from questionnaires and data envelopment analysis (DEA) approach. Moreover, the performance of RE and the new IRE are compared and discussed. The results show that although there is a strong direct correlation between the DEA results in two frameworks, the mean scores of efficiency in IRE is slightly higher than RE. This is the first study that introduces an integrated approach for RE. In addition, this study is amongst the first ones that examine the behavior of resilience engineering by DEA. Moreover, the superiority of IRE is shown through robust statistical analysis.     

A research model--forecasting incident rates from optimized safety program intervention strategies

INTRODUCTION/PROBLEM: Property damage incidents, workplace injuries, and safety programs designed to prevent them, are expensive aspects of doing business in contemporary industry. The National Safety Council (2002) estimated that workplace injuries cost $146.6 billion per year. Because companies are resource limited, optimizing intervention strategies to decrease incidents with less costly programs can contribute to improved productivity. METHOD: Systematic data collection methods were employed and the forecasting ability of a time-lag relationship between interventions and incident rates was studied using various statistical methods (an intervention is not expected to have an immediate nor infinitely lasting effect on the incident rate). RESULTS/SUMMARY: As a follow up to the initial work, researchers developed two models designed to forecast incident rates. One is based on past incident rate performance and the other on the configuration and level of effort applied to the safety and health program. Researchers compared actual incident performance to the prediction capability of each model over 18 months in the forestry operations at an electricity distribution company and found the models to allow accurate prediction of incident rates. IMPACT ON INDUSTRY: These models potentially have powerful implications as a business-planning tool for human resource allocation and for designing an optimized safety and health intervention program to minimize incidents. Depending on the mathematical relationship, one can determine what interventions, where and how much to apply them, and when to increase or reduce human resource input as determined by the forecasted performance.     

实施OSHMS对企业职业安全健康管理状况影响分析

为了研究实施职业安全健康管理体系(OSHMS)对企业职业安全健康管理状况的影响,对百余家已实施与未实施OSHMS的企业进行了调研,在对调研结果分析研究的基础上,采用双对照分析的方法,对已通过OSHMS认证的企业在建立OSHMS前后的职业安全健康管理状况进行对照比较,以及已建立OSHMS与未建立OSHMS的企业的职业安全健康管理状况进行对照比较,研究结果表明,实施OSHMS有利于提高企业职业安全健康管理的整体水平,改善企业的职业安全健康管理状况,使职业安全健康管理更加科学化和规范化。     

打造零事故的建筑安全文化

在研讨安全文化和建筑安全文化内涵,分析国内外建筑安全文化研究与国内实施现状的基础上,研究了5家国际建筑企业的安全创新活动,包括:企业背景、方案、实施过程等。结合利害关系者原理、风险管理和安全知识管理,笔者提出:要实现安全行为,应注重塑造员工的安全信念、态度和承诺;应有高层管理人员强有力的支持,将整个建筑业供应链的利害关系者都纳入到安全管理中,风险管理和安全知识管理的运用可促进零事故安全文化的形成。同时提出构建在我国实现零事故的建筑安全文化的流程,即承认-启动-执行-监督-更新的步骤,给出了一种提高员工安全知识、坚定员工安全信念、塑造员工安全态度、形成安全行为并最终打造健全安全文化的整体策略。     

Values-in-action that support safe production

Introduction: Safe production is a sustainable approach to managing an organization’s operations that considers the interests of both management and workers as salient stakeholders in a productive and safe workplace. A supportive culture enacts values versus only espousing them. These values-in-action are beliefs shared by both management and workers that align what should happen in performing organizational routines to be safe and be productive with what actually is done. However, the operations and safety management literature provides little guidance on which values-in-action are most important to safe production and how they work together to create a supportive culture. Method: The researchers conducted exploratory case studies in 10 manufacturing plants of 9 firms. The researchers compared plant managers’ top-down perspectives on safety in the performance of work and workers’ bottom-up experiences of the safety climate and their rates of injury on the job. Each case study used data collected from interviewing multiple managers, the administration of a climate survey to workers and the examination of the plant’s injury rates over time as reported to its third party health and safety insurer. Results: The researchers found that plants with four values-in-action —a commitment to safety, discipline, prevention and participation—were capable of safe production, while plants without those values were neither safe nor productive. Where culture and climate aligned lower rates of injury were experienced. Discussion and conclusion: The four value-in-actions must all be present and work together in a self-reinforcing manner to engage workers and managers in achieving safe production. Practical application: Managers of both operations and safety functions do impact safety outcomes such as reducing injuries by creating a participatory environment that encourage learning that improves both safety and production routines.     

Measuring safety culture in a research and development centre: A comparison of two methods in the Air Traffic Management domain

This paper describes two safety surveys carried out in an Air Traffic Management Research and Development centre (EUROCONTROL Experimental Centre). The paper discusses the differences and similarities between the two tools with regard to their development, the method of conducting the surveys, the results and their implications. It has been estimated that about 50%¹ to 60%² of accidents and incidents appear to have their roots in the design and development process, and since this is the core business of the EEC, it was deemed necessary to investigate the maturity of safety at the EEC. The challenge for the EUROCONTROL Experimental Centre (EEC) was to develop a tool that is relevant to a research and development environment with the objectives of (i) identifying areas of weakness in the safety culture of the organization (ii) helping in developing a Safety Management System. The first objective was addressed by developing a Safety Culture Survey (SCS) tool and surveying the EEC (March, 2003). The second objective was addressed by customizing an existing (SMS) survey tool (RD) for the R&D environment. The SCS is based on traditional measures adapted to ATM and then to R&D, and the River Diagram (RD) is more of a safety management survey, adapted from other industries and already applied to HQ (EUROCONTROL Head Quarters) to examine their commitment to safety. Nevertheless, the two surveys have been compared to see where they agree and where they ‘dissociate’. Overall, the SCS has a broader focus on “softer issues”, i.e. more complex issues of ‘trust in management’. Diagnostically, the River Diagram survey helps the practitioner develop SMS implementation plans more readily than the Safety Culture survey.     

Modeling the effects of production pressure on safety performance in construction projects using system dynamics

Introduction: Construction incidents occur due to system failures, not due to a single factor such as unsafe behavior or condition. Therefore, construction safety should be investigated using a systematic view capable of illustrating the complex nature of incidents. Construction projects are also often behind their planned schedule and suffer from various pressures caused by contractual deadlines or clients. Previous studies demonstrated that such pressures negatively affect safety performance; however, the process of how production pressure influences safety performance is not fully investigated. Method: The present research aimed to understand the feedback mechanism of how production pressure interactively affects safety performance and safety-related managerial components in a construction project. Ground theory method (GTM) is used to create a conceptual causal loop diagram that shows the relationship between incident rate and other variables such as labor hour, actual and planned progress, safety climate, rework, and safety training. Moreover, a power plant construction project was used as a case study to practically investigate the conceptual model; a case study is employed to build a System Dynamics (SD) model. The simulation model was then validated using behavior reproduction and sensitivity analysis. Results: The results of the inequality statistics show that the simulation model can be used to forecast trends in the incident rate.     

The effect of integrated management system on safety and productivity indices: Case study; Iranian cement industries

Nowadays, with implementation of management systems and environment management and due to the influence of safety and health issues on working processes, organizations have also sought to acquire health and safety management systems. This study which aims to examine the influence of integrated management system on safety and productivity indices has retrospective experimental nature. It was conducted in Cement Factories in which three systems are used: quality, environment and safety systems. The collected data were: accident reports and the investigation of events in 6 years during 2005-2010 (3 years before and 3 years after the implementation of the system). The safety indices that used in this study are: IFR, ISR, FSI, and Safe T. Score. Then, the data analyzed with the T-test, mean and standard deviation. The results showed a significant difference between various safety indices before and after the implementation. The examination of production indices such as increasing rate of productivity and production indicates the influence of these systems on production and productivity indices. The results have showed that the safety system existence cannot ensure productivity increase. Indices definition can be helpful for the safety system effectiveness and system continual improvement. It is important to say that there might be various indices definition in different industries.     

Comparing safety climate factors as predictors of work-related driving behavior

INTRODUCTION: Research suggests safety climate (SC) is a strong predictor of safety-related outcomes in organizations. This study explores the relationship between six SC dimensions and four aspects of work-related driving. METHOD: The SC factors measured were "communication and procedures," "work pressures," "relationships," "safety rules," "driver training," and "management commitment." The aspects of self-reported occupational driving measured were traffic violations, driver error, driving while distracted, and pre-trip vehicle maintenance. RESULTS: Hierarchical regression analyses revealed that the SC factors accounted for significant amounts of variance in all four aspects of work-related driving, over and above the control factors of age, sex, and work-related driving exposure. However, further investigation indicated certain SC factors (particularly safety rules, communication, and management commitment) were more strongly related to specific aspects of work-related driving behavior than others. Together, the SC factors were better able to predict self-reported distraction from the road than the other aspects of driving behavior measured. Implications for occupational safety, particularly for the management of work-related drivers are discussed.