Learning lessons from incidents: A paradigm shift is overdue

Drawing on historical data we show that the international community of process engineers has not been good at learning lessons from their past accidents. We call for a paradigm change in the way we approach this and the creation of a single new, multi-national, multilingual accident database that is free at the point of use and that includes immediate and underlying causes as well as “lessons learned”. It must be user-friendly and provide links to key source documents. The purpose of this paper is to challenge those in authority, and with the power to do so, to make this happen. We give some preliminary views on what may be required. In countries that so choose this could include an element of compulsion to consult the database in specific circumstances and a sign-off procedure to verify that this has been done.     

Three accidents in European dynamite production plants: An attempt to improve the external lessons learning

Three serious accidents occurred in three dynamite manufacturing plants within three European countries during a relatively short time period triggering the question of effective external learning. The article discusses the lessons for the prevention of accidents learned from retrospective comparative analysis. It advocates for a better process for learning lessons. It attempts to show how a two level approach to accident analysis may help to reveal a common deeper learning hidden under diverse routine lessons.     

Building resilience into emergency management

Emergency management faces a changed reality in terms of possibilities and threats with use of new technology. Due to the ongoing changes in the operation of oil and gas production, different constellations of actors in a distributed system are built. This introduces opportunities for planning and operation. At the same time as new technology offers opportunities, the technology-enabled distributed network of actors generate challenges for emergency handling. The purpose of the study presented has been to look for possibilities for making emergency management more resilient by becoming a part of continuous risk and hazard management. The suggested three main elements that are important to consider in the development of future emergency management are (1) proactive emergency management through early risk anticipation; and emergency management’s adaptation to new and future work practices such as (2) distributed actors and (3) new technology. Based on these results we suggest broadening the scope of emergency management to systematically include monitoring, anticipation, responding and learning.     

Higher-order driving instruction and opportunities for improvement: Exploring differences across learner driver experience

Introduction: Few studies have investigated what guidance occurs during the Learner phase of driving, particularly during formal lessons. The objective of this research was threefold: (a) investigate functional and higher-order driving instruction (HO-DI) in formal Learner lessons, (b) explore teaching approaches within the context of a theoretical framework, and (c) investigate variation in these three elements of instruction as a function of Learner driving experience. The theoretical framework developed to guide this research integrated the constructivist Goals for Driver Education and self-determination theory. Method: Professional instruction was explored through naturalistic observation; 15 instructors provided GoPro recordings of 110 driving lessons with Learners aged 16–19 years (n = 96) at varying levels of experience: Early (<20 logbook hours), Mid (21–70 h), and Late (71–>100 h). Results: Employing a previously-developed coding taxonomy, instructor guidance opportunities were identified as 15% HO-DI, 73% functional instruction, and 12% untaken or missed HO-DI. Functional instruction peaked in the Mid Phase, while HO-DI was prominent in the Early phase suggesting missed opportunities in the later phases when use of silence peaked. Some elements of self-determination theory’s needs-supportive model were readily identified in teaching approaches, such as feedback. Conclusions: An understanding of functional and HO-DI, including teaching strategies, was established within the context of an integrated theoretical framework, with different trajectories across Learner experience identified. Teaching strategies reflected constructivism and self-determination theory providing theoretical support for these frameworks to be applied in future driver training studies. Continued research efforts are needed to understand how best to balance functional and HO-DI to maximize young novice drivers’ learning prior to independent driving, particularly during the late Learner period. Practical Applications: Naturalistic observation of current HO-DI and teaching approaches supports the feasibility of integrating recommended improvements arising from the theoretical framework within current practice, with practical implications for improvements to industry training.     

Focus on mission success: Process safety for the Atychiphobist

Modern process plants are complex engineering systems. While thorough reviews of system safeguards are performed, catastrophic events continue to occur, often unfolding in unforeseen ways. Success in process safety demands safe processes, and understanding rare, high consequence events is central to the traditional process safety approach. This philosophy is common to all high-hazard industries, offering the potential for sharing approaches, experience, and lessons learned. The problem, however, is that people (and organizations and entire industries) who fear failure (atychiphobia) sometimes obsess about failure so much that they miss opportunities to succeed.This paper examines selected risk management practices in the power generation and aerospace industries and how those practices have led to improved performance. Risk informed decision making (RIDM) has had widespread application in the nuclear and aerospace industries, and is undergoing enhancements to become a key framework for risk management. Additionally, rather than focusing on avoidance of loss, there are emerging approaches supporting achievement of success. This approach provides a more direct link of risk to business and operational objectives, but does challenge conventional risk approaches founded in a loss prevention-centric view. The paper reflects upon risk informed decision making and success modeling, and suggests how these methods may be applied in the field of process safety. Specific examples are drawn from the defense in depth approach from the nuclear power industry and mission success concepts developed for NASA.     

Learning from the Bhopal disaster to improve process safety management in Singapore

The Singapore process industry is mainly made up of chemical and energy companies such as Mitsui Chemicals, Clariant, Exxon Mobil, Shell, Sumitomo, Petrochemical Corporation of Singapore and Infineum. Majority of these companies are located on Jurong Island, southwest of Singapore. Jurong Island houses nearly 100 leading petroleum, petrochemicals and specialty chemicals companies and the total investment is about S$42 billion in total. With a land surface area of only 716 km² and a high concentration of process plants, the Singapore government places strong emphasis on safety and risk management. In this paper, four process industry veterans from the government, academic and private sectors were interviewed. Through the interviews, the authors sought to understand the veterans’ perspectives on lessons that the Singapore process industry should learn from the Bhopal disaster. The veterans expanded their thoughts beyond the Bhopal disaster and provided many insights and suggestions critical to process safety management in Singapore and other countries. A systemic model of process safety management was derived from the interviews and key elements of operational process safety management were identified. In addition, a research agenda was identified based on the inputs from the veterans.     

Seeking to improve care for young patients: Development of tools to support the implementation of the CDC Pediatric mTBI Guideline

IntroductionThe Centers for Disease Control and Prevention (CDC) Pediatric Mild Traumatic Brain Injury (mTBI) Guideline was created to help standardize diagnosis, prognosis, and management and treatment of pediatric mTBI. This paper describes the process CDC used to develop educational tools, and a dissemination and implementation strategy, in support of the CDC Pediatric mTBI Guideline.MethodsTwo qualitative data collection projects with healthcare providers who care for pediatric patients were conducted. In-depth interviews were used in both projects. Project One examined healthcare providers' guideline use and dissemination preferences. Project Two assessed perceptions of the CDC Pediatric mTBI Guideline educational tools.ResultsProject One brought to light four key areas related to Guideline usage and dissemination preferences, specifically a need for: (1) partnership with professional medical societies; (2) integration into electronic health records, mobile apps, and websites; (3) development of continuing medical education (CME) opportunities; and (4) dissemination through healthcare system leadership. In Project Two, healthcare providers reported that the CDC Pediatric mTBI Guideline educational tools were well-organized, clear and easy to navigate, and informative. Healthcare providers also requested more information on the Guideline methodology.DiscussionAssessment of pediatric healthcare providers' current use of clinical guidelines and preferences for educational tools yielded important insights that helped inform CDC's dissemination and implementation strategy for the Pediatric mTBI Guideline.Practical applicationsThe findings from these data collection projects can also inform other guideline implementation and dissemination efforts among healthcare providers.     

基于单值中智集VIKOR的应急群体决策方法

针对在突发事件应急决策中,属性权重信息完全未知且决策信息以单值中智集形式给出的多属性群体决策问题,提出1种基于多准则妥协解排序的应急群体决策方法。利用中智熵确定属性权重,基于单值中智数模糊性测度确定专家权重,利用单值中智集加权平均算子集结群体信息;将VIKOR方法扩展到单值中智数环境下,对备选方案进行排序择优;最后,通过1个应急突发事件案例验证决策方法的可行性和有效性。     

Professional ethics and corporate social responsibility

Sharing accident information and learning the lessons is an important way of reducing errors in any industry. All human beings make errors at some time and it is necessary that design and operational work must be capable of dealing with human fallibility. It is necessary for a management system in all companies to deal with the sharing of information and the learning of lessons from the information. Companies have been reluctant to share information and engineers reluctant to provide information on accidents for fear of the consequences. This paper deals with the ethics issue of the engineer and the social responsibilities of companies to their employees and the public. It is proposed that the professional bodies should make efforts to ensure companies share accident information so that the risks involved in the industry are reduced for the benefit of all.     

Rail ruminations for process safety improvement

Process safety practices have undergone multiple refinements over the past few decades, but major accidents continue to occur. Most organizations strive to improve performance by strengthening existing methods or by adopting new and/or different approaches. Central to these continual improvement efforts is the practice of applying lessons learned as a means to drive out potential risk exposures. Often, lessons learned may be transferred from other industries; indeed, high-performing organizations regularly benchmark practices outside of their immediate industry.In pursuit of continual process safety improvement, this paper examines risk management practices in the Rail Industry, and explores how methods intended for managing passenger and public rail safety may be transferred to drive continual improvement of process safety. Rail safety has its roots in engineered safety solutions; modern practices have additionally embraced the human aspects of safety performance. A selection of approaches for rail safety assessment and risk management are described in three areas considered fundamental to safety management: management of systems, management of technology, and management of human elements. In light of these examples, the authors provide views regarding how the field of process safety management may leverage the rail experience.     

Insights into process safety incidents from an analysis of CSB investigations

Many incidents have helped to define and develop process safety. Each has provided valuable learning opportunities. However, it is even more important to identify insights that can be obtained from an analysis of a large set of incidents that represents those that typically occur. This larger picture illuminates trends and commonalities and provides learning opportunities that are even more important than the causes of any one individual incident.The Chemical Safety Board has published the results of over 60 investigations of process safety incidents. These data have been analyzed to identify commonalities and trends so that measures to help protect against future incidents can be developed. Recommendations are made to address key issues identified.     

Lessons learnt from a crisis event: How to foster a sound safety culture

Recent events in the nuclear industry have blamed a declining safety culture both on the utility and regulatory side as the major responsible. Confidence in the nuclear industry can be dramatically affected by such events. In this context, the present paper analyses a recent crisis event that involved a research reactor. It shows the time history of the event and how its escalation brought to a temporary shut down of the reactor. In-depth analysis of the event pointed out safety culture deficiencies within the organization. The paper presents the key elements in the ensuing organizational change process and describes the different phases (short and long term approaches), players and measures involved in the process that the organisation set up to address deficiencies and improve safety culture. The case represents an interesting example from which important lessons can be learnt. In particular, staff motivation in terms of involvement in improvement activities is considered central in managing safety.     

The bumpy road to better risk control: A Tour d'Horizon of new concepts and ideas

How can we be sure that sufficient safeguards are in place and safety level is acceptable? As we heard Prof. Nancy Leveson stating at last year's MKOPSC symposium, even with all components functioning, dysfunctional component interaction can still be a cause of mishap. Human factor expert, Prof. Erik Hollnagel, asserts it in even stronger terms: the Efficiency-Thoroughness Trade-off principle, or rather dilemma, contends that one can hardly do it perfectly well. Perfect thoroughness, certainly in complex situations, requires an amount of time with which efficiency will be in conflict. For improved situational awareness, sufficient resilience, and adequate risk control, we must adopt a top-down system approach. Hazard scenarios possible in the system, with all its entangled interactions of hardware, procedures, and humans shall be identified bottom-up and causal relations made clear. Fortunately, in recent years two potentially helpful tools have become available: Blended Hazid, a vastly improved, heavily computerized system approach making use of HazOp and FMEA, and Bayesian networks, a tool to model cause–effect structures allowing inclusion of uncertainty information. Bayesian networks as an infrastructure enable also the use of indicator values to relate the result of safety management effectiveness, which expresses itself as safety attitude of employees, competence, workload, and motivation, with their effects on error and failure probability. This paper will explain the directions these developments are advancing and the openings they provide for further process safety research and risk assessment, which when applied will result in improved process risk control.     

An adaptive management system for hazardous technology organizations

This paper introduces a management system suitable for hazardous technology organizations which has been developed based on the assumptions that in these organizations safety is a critical strategic factor, the existence of an enhanced safety culture is a crucial condition for safety and that safety culture enhancement implies in organizational changes. The management system was theoretically developed and then implemented at a Brazilian nuclear research and development installation, as a case study, in order to validate the theoretical propositions assumed in the system development. The developed management system comprises a day-to-day based organizational framework which treats safety as one of the organization strategic perspectives and provides a continuous adaptation of the complex causal inter-relationships which occur between the implementation of new management practices – designed and implemented according to the requirements of the criteria of excellence of the Brazilian quality award management assessment model – and the organization safety culture. The results achieved in the case study permitted to demonstrate the validness of all the system theoretical propositions and to conclude that the continuous and systematic operation of the management system makes an effective safety culture enhancement possible and simultaneously facilitates that the new management practices be effectively implemented, thus making continuous organizational improvement possible.     

Seat-belts and behavioural adaptation: the loss of looming as a negative reinforcer

Janssen has shown that drivers adopt slightly higher speeds and shorter following distances over the year after they switch from non-use to use of seat-belts. Does such behavioural adaptation continue to grow, so that the benefit for seat-belt users becomes dubious? One problem in answering this has been the weak theoretical basis of behavioural adaptation. In this paper, Fuller's learning model is developed as an alternative. The sharp braking associated with near-misses and other circumstances pitches an unbelted motorist towards the internal fittings of the automobile, thus eliciting rapidly accelerating visual expansion leading to defensive and fear responses. This looming phenomenon acts as a negative reinforcer by which safer driving behaviours become learnt. Seat-belt use removes looming. Learning due to negative reinforcement is persistent, so those switching from non-use to use of seat-belts only lose their safer driving behaviours over a long time. Also, in the years after seat-belt legislation is introduced increasing numbers of new licence-holders will have always used seat-belts, so looming will never affect their learning. This analysis suggests that seat-belt use has dubious long-term effectiveness for motorists, while engendering a more dangerous roadway environment for non-motorists.     

Traffic safety in the U.S.: re-examining major opportunities

INTRODUCTION: This article examines five major road-safety risk factors: exceeding posted speed limits, not using safety belts, driving while intoxicated, nighttime driving, and young drivers. METHOD: The importance of each of these factors is documented, known effective countermeasures (both policy and technology based) are discussed, and impediments to the implementation of these countermeasures in the United States are examined. RESULTS: Based on current understanding of the five major risk factors, and of the available countermeasures, there appear to be a variety of opportunities to make substantial gains in road safety using existing knowledge. The limited implementation of a variety of known countermeasures therefore appears to be inconsistent with high-level, strategic goals to improve road safety. Consequently, a recommendation is made to comprehensively re-examine the balance between the countermeasures discussed in this article and economic, mobility, and privacy concerns. IMPACT ON PUBLIC SAFETY: Such a re-examination is likely to result in broad support for these countermeasures, with a consequent major improvement in road safety.