Reconstructing human contributions to accidents: the new view on error and performance

PROBLEM: How can human contributions to accidents be reconstructed? Investigators can easily take the position a of retrospective outsider, looking back on a sequence of events that seems to lead to an inevitable outcome, and pointing out where people went wrong. This does not explain much, however, and may not help prevent recurrence. METHOD AND RESULTS: This paper examines how investigators can reconstruct the role that people contribute to accidents in light of what has recently become known as the new view of human error. The commitment of the new view is to move controversial human assessments and actions back into the flow of events of which they were part and which helped bring them forth, to see why assessments and actions made sense to people at the time. The second half of the paper addresses one way in which investigators can begin to reconstruct people's unfolding mindsets. IMPACT ON INDUSTRY: In an era where a large portion of accidents are attributed to human error, it is critical to understand why people did what they did, rather than judging them for not doing what we now know they should have done. This paper helps investigators avoid the traps of hindsight by presenting a method with which investigators can begin to see how people's actions and assessments actually made sense at the time.     

Safety Management in Coal Mines—Risk Assessment

The present state of accident hazard at work in the Polish mining industry is presented. A comparison is made of the accident indices in relation to other countries. A reference is made to the work safety management system implemented in the mines. Safety management is discussed in terms of risk management. On the basis of the natural death index and that of accidents at work, numerical scales are presented defining the limits of the inadmissable, tolerable, and acceptable risk. The course of variation of risk indices for fatal, serious, and minor accidents is evaluated. The results of the assessment for all kinds of accidents at work in the mining industry are presented.     

Risk assessment tools incorporating human error probabilities in the Japanese small-sized establishment

Although it has been estimated that as many as 80% of all occupational accidents have human errors as a cause, no risk assessment tools incorporating human-related elements have been developed for small companies. Human error probability (HEP) and human error analysis (HEA) have been used for large-scale, safety-critical industries for last three decades, but these tools are not suitable for smaller, more general industries that comprise the majority of accident settings.Here, we describe and verify a risk assessment tool that includes human-related elements for small companies. The tool expands on traditional risk assessment methods, such as matrix, risk graph and numerical scoring method, by adding human-related elements. The tool is easy-to-use in occupational environments, and includes assessments of human behavior and potentially outdated machinery at work place.     

Predictive Model for Motorcycle Accidents at Three-Legged Priority Junctions

In conjunction with a nationwide motorcycle safety program, the provision of exclusive motorcycle lanes has been implemented to overcome link-motorcycle accidents along trunk roads in Malaysia. However, not much work has been done to address accidents at junctions involving motorcycles. This article presents the development of predictive model for motorcycle accidents at three-legged major-minor priority junctions of urban roads in Malaysia. The generalized linear modeling technique was used to develop the model. The final model reveals that motorcycle accidents are proportional to the power of traffic flow. An increase in nonmotorcycle and motorcycle flows entering the junctions is associated with an increase in motorcycle accidents. Nonmotorcycle flow on major roads had the highest effect on the probability of motorcycle accidents. Approach speed, lane width, number of lanes, shoulder width, and land use were found to be significant in explaining motorcycle accidents at the three-legged major-minor priority junctions. These findings should enable traffic engineers to specifically design appropriate junction treatment criteria for nonexclusive motorcycle lane facilities.     

Predictive model for motorcycle accidents at three-legged priority junctions

In conjunction with a nationwide motorcycle safety program, the provision of exclusive motorcycle lanes has been implemented to overcome link-motorcycle accidents along trunk roads in Malaysia. However, not much work has been done to address accidents at junctions involving motorcycles. This article presents the development of predictive model for motorcycle accidents at three-legged major-minor priority junctions of urban roads in Malaysia. The generalized linear modeling technique was used to develop the model. The final model reveals that motorcycle accidents are proportional to the power of traffic flow. An increase in nonmotorcycle and motorcycle flows entering the junctions is associated with an increase in motorcycle accidents. Nonmotorcycle flow on major roads had the highest effect on the probability of motorcycle accidents. Approach speed, lane width, number of lanes, shoulder width, and land use were found to be significant in explaining motorcycle accidents at the three-legged major-minor priority junctions. These findings should enable traffic engineers to specifically design appropriate junction treatment criteria for nonexclusive motorcycle lane facilities.     

基于HFACS的化工企业火灾爆炸事故人因分析*

为研究化工企业火灾爆炸事故的主要人为因素,以63起火灾爆炸事故案例为样本,构建人为因素分析与分类系统（HFACS）模型,进行火灾爆炸事故人为因素分类统计与分析,并利用卡方检验和比值比分析HFACS模型上下层级间的因果关系。结果表明:HFACS模型中上下层级人为因素间存在显著的因果关系,层级1中的“不良的组织氛围”及“组织过程漏洞”和层级2中“监督不充分”在HFACS模型中可以显著增大事故发生的可能性,且“资源管理漏洞”、“不良的组织氛围”、“组织过程漏洞”→“监督不充分”→“人员因素”→“违规”是引发事故的关键路径,并根据HFACS模型中引发事故的关键路径及其人为因素的主要表现形式,提出针对性的化工企业火灾爆炸事故预防措施。     

Mapping human vulnerability and risk due to chemical accidents

Chemical accidents in the vicinity of densely populated areas can cause colossal damage. Close proximity of chemical facilities to the general public has been identified as a major issue for increased human exposure in 43% of the accidents investigated by the U.S. Chemical Safety Board (CSB). This emphasises the need for incorporating societal factors in risk assessment to plan actions in order to minimise exposure during accidents. The purpose of this research is to develop a model for the assessment of human vulnerability and risk due to chemical accidents. A GIS based methodology is proposed which uses computer aided hazard modelling tools and technical guidelines to model accidents and assesses population vulnerability. The population vulnerability is determined based on a set of societal indicators derived from relevant research work, expert opinions and suggestions by World Bank. Risk is defined as the probable magnitude of harm to humans and dependent on both the degrees of hazard and vulnerability. A case study is carried out by applying the methodology to Meghnaghat Industrial Area in Bangladesh. Accident scenarios are built and hazard modelling software ALOHA is used to spatially display accident footprints. Vulnerability of population is assessed using data from Bangladesh Bureau of Statistics (BBS) and field survey. The hazard footprints and vulnerability map are superimposed using mapping software ArcGIS to generate a composite risk map. The risk map is used to assess existing land use and recommendations are made for future land use planning. The composite risk map is expected to be of help for effective community response, emergency response planning and allocation of medical and support services during emergencies.     

基于“2-4模型”的化工生产事故原因分析

为进一步研究化工生产事故发生的原因,运用“2-4模型”对从安全管理网等网站收集的125起化工生产安全事故进行分析,结果表明对于事故的直接原因方面,作业人员的不安全动作主要表现在违规操作和无证上岗,管理人员的不安全动作主要表现在其工作不认真等方面,不安全物态最主要的是设备年久失修。对于事故的间接原因,主要表现在安全意识不够、安全知识不足、安全习惯不佳3方面。事故的根本原因则主要表现在缺乏安全培训等方面。为制定化工生产事故预防措施提供了依据。     

Allocation of performance shaping factors in the risk assessment of an offshore installation

Offshore oil production is one of the most important human productive activities. There are many risks associated with the process of constructing a subsea well, pumping oil to the platform, and transporting it to refineries via underwater pipes or oil tankers. All actions performed by workers in those operations are influenced by specific working conditions, involving the use of complex systems. Contextual factors such as high noise, low and high temperatures and hazardous chemicals are considered to be contributors to unsafe human actions in accident analysis and also give a basis for assessing human factors in safety analysis. Some failure modes are particularly dangerous and can result in severe accidents and damage to humans, the environment and material assets. Fires and explosions on oil rigs are some of the most devastating types of offshore accidents and can result in long-term consequences. The most typical root causes related to accidents include equipment failure, human error, environmental factors, work organization, training and, communication, among others. The principal objective of this study is to propose a methodological framework to identify the factors that affect the performance of operators of an offshore unit for oil processing and treatment. In this phase, an ergonomics approach based on operators' work analysis is used as a supporting tool. After identification of factors that affect the performance of operators, a decision-making model based on AHP (analytic hierarchy process) is applied to rank and weight the principal performance shaping factors (PSFs) that influence safe operations. The next step involves the use of the SHELLO model to group the main PSFs in elements named software, hardware, environment, liveware and organization. In the last phase, a relevant accident that occurred aboard a floating production storage and offloading (FPSO) vessel is analyzed. The allocation process of the factors that affect the operator's performance in risk assessment was developed through fuzzy logic and the ISO 17776 standard.     

Are pilots at risk of accidents due to fatigue?

PROBLEM: There is concern in the aviation community that pilot schedules can lead to fatigue and increased chance of an aviation accident. Yet despite this concern, there is little empirical analysis showing the relationship between pilot schedules and commercial aviation accidents. This study attempts to demonstrate an empirical relationship between pilot schedules and aviation accidents. METHOD: Data for human factors-related accidents and pilot work patterns were identified. The distribution of pilot work schedule parameters for the accidents was compared to that for all pilots using a chi-square test to determine if the proportions of accidents and length of duty exposure were the same. If the distributions are the same, then one could infer that pilot human factor accidents are not affected by work schedule parameters. RESULTS: The proportion of accidents associated with pilots having longer duty periods is higher than the proportion of longer duty periods for all pilots. DISCUSSION: There is a discernible pattern of increased probability of an accident as duty time increases for commercial aircraft pilots in the United States. IMPACT ON INDUSTRY: The analysis suggests that establishing limits on duty time for commercial pilots would reduce risk. Such a rule is likely to be expensive and could substantially impact the commercial airlines. In return, there is likely to be a reduction in the risk of commercial aviation accidents due to pilot fatigue.     

煤矿人为事故发生可能性预测数学模型研究

研究发现，煤矿工人的冒险行为主要可以由生产条件、个人表现、工作状况及用工方式等影响因素预测，煤矿人为事故的发生可能性主要由煤矿工人的冒险行为表现预测。据此，便可建立预测煤矿人为事故发生可能性的数学模型     

Analysis on causes of chemical industry accident from 2015 to 2020 in Chinese mainland: A complex network theory approach

Chemical manufacturing is a long-process industry, where an end product may pass through numerous dangerous and complex steps. In such long chains of coordinated activity, accidents remain common. This study made loss-prevention recommendations for the chemical industry after conducting a review of accident reports and creating a complex network model. A human factor analysis and classification system (HFACS) was used to classify data from 109 investigation reports from the Chinese mainland (2015–2020). Levels Ⅱ and Ⅲ of the HFACS output were fed into a complex network model to generate a map of causes and chains of risk. It was shown that most accidents were directly or indirectly caused by human action, and human factors played a decisive role in occurrence, evolution, and resolution. The model used was visualized in Gephi, and the key cause nodes were identified by their topological characteristics. A modularity algorithm was used to derive the community structures and segment the network map. Crucial nodes in each community were compared with factors for each class in the HFACS model. It was also found that there was a biasing factor in the causal processes of explosive accidents and poisoning and asphyxiation accidents according to the associations classified by modularity. Risk abatement strategies were proposed for the crucial factors.     

关于工业机器人的事故分析及其对策

工业机器人是高科技机电产品，在工业领域广泛应用，可以代替人们从事繁重的、危险性的工作，但由于工业机器人故障所造成的人身伤害事故也时有发生，从工业机器人的可靠性、工业机器人事故案例、能量类型分类等多角度对工业机器人事故进行了分析，从事故树分析法（FTA）、基本安全性原则、工业安全技术等几方面提出了相应的对策。     

基于信息融合的建筑施工安全预警管理研究

针对建筑业安全事故率居高不下的现状,找出事故频发的主要原因。基于主要原因中人、机、环境和管理4方面数据和信息的复杂性、不确定性,提出采用信息融合技术的D-S证据理论法对建筑施工全过程中的人、机、环境、管理4方面的数据和信息进行分析和预测,并构建建筑施工安全预警管理预测模型。该预测模型能判断建筑施工项目的"安全状态",能解决建筑施工中安全事故及危险源的预测问题;同时针对具体情况采取防范措施,及时矫正安全隐患和确保安全施工。将D-S证据理论法应用于建筑施工安全预警管理中,扩展了建筑施工安全管理的手段。     

Equipment failures and their contribution to industrial incidents and accidents in the manufacturing industry

Accidental events in manufacturing industries can be caused by many factors, including work methods, lack of training, equipment design, maintenance and reliability. This study is aimed at determining the contribution of failures of commonly used industrial equipment, such as machines, tools and material handling equipment, to the chain of causality of industrial accidents and incidents. Based on a case study which aimed at the analysis of an existing pulp and paper company's accident database, this paper examines the number, type and gravity of the failures involved in these events and their causes. Results from this study show that equipment failures had a major effect on the number and severity of accidents accounted for in the database: 272 out of 773 accidental events were related to equipment failure, where 13 of them had direct human consequences. Failures that contributed directly or indirectly to these events are analyzed.     

化工园区泄漏事故安全风险评估模式研究

为减少化工事故频发造成严重人员伤亡及财产损失,在分析危化品泄漏事故类型的基础上,从事故发生概率和事故后果两方面提出危化品泄漏事故风险评估模型.以中毒事故为例,对重庆长寿化工园区内某企业一液氨储罐进行风险评估.基于概率模型计算中毒事故概率,结果表明该储罐发生泄漏引起中毒的概率较小;数值模拟结果显示:影响范围随时间的增加而...     

基于动态风险平衡的海洋平台事故连锁风险研究

针对海洋平台事故风险特点,提出动态风险平衡概念,以此建立事故动力模型,并将该模型运用到墨西哥湾"深水地平线"井喷事故。动态风险平衡表征事故动力与事故阻力之间的动态平衡状态,具有动态性和暂时稳定性。事故动力模型以海洋平台可能发生的重大事故为研究对象,从工艺、技术和管理等角度分析事故可能致因和事故发展可能影响因素。该模型首先分析对象的初始事故动力,建立事故连锁风险图,然后计算初始动力发生情况下,传递动力和传递阻力的概率分布,最后提出相应风险控制措施。实例分析表明,基于动态风险平衡建立的事故动力模型能有效分析海洋平台事故连锁风险。     

Occupational and public health and safety in a changing work environment: An integrated approach for risk assessment and prevention

During recent years the work environment has undergone significant changes regarding working time, years of employment, work organization, type of employment contracts and working conditions. In this paper, consequences of these changes on occupational and public health and safety are examined. These include the disruption of human biological rhythms, the increase of workers fatigue due to changes in patterns of working hours and years of employment, job insecurity and occupational stress, which have a serious impact on workers’ health and may result in an increase in occupational accidents. Unsafe work practices related to workload and time pressure, the impact of work changes on public safety and the deterioration of workers’ living conditions with respect to income, social-family life, health and insurance benefits, are also described. In this context, difficulties that occur due to the changing work environment in conducting effective occupational risk assessments and implementing OSH measures are discussed (for example, frequent changes between tasks and workplaces, underreporting of occupational accidents and diseases, lack of methodological tools, etc.). A fundamental criterion used while studying consequences on health and safety and the relative preventive measures is that health and safety must be approached as ‘the promotion and maintenance at the highest degree of the physical, mental and social well-being of workers’ and not only as retention of their work ability. Limits in combining “flexibility” at work and overall protection of occupational and public safety and health in a competitive market are put forward for discussion.     

Global estimates of occupational accidents

Information of occupational accidents is not standardized worldwide. Especially, developing countries do not have reliable information on their occupational accidents due to lack of proper recording and notification systems. The number of accidents is under-reported but figures are still used as a baseline for occupational safety work. In this paper global estimates of occupational accidents are presented for 175 countries. These estimates are based on figures from selected countries in eight different regions. Global estimates help to compare different countries and regions to each other to detect improvements in safety and safety work. In 1998 the average estimated number of fatal occupational accidents was 350 000 and there were 264 million non-fatal accidents. Global estimates are needed to guide national policies and decision-making.