Classification of errors contributing to rail incidents and accidents: A comparison of two human error identification techniques

Identifying the errors that frequently result in the occurrence of rail incidents and accidents can lead to the development of appropriate prevention and/or mitigation strategies. Nineteen rail safety investigation reports were reviewed and two error identification tools, the Human factors analysis and classification system (HFACS) and the Technique for the retrospective and predictive analysis of cognitive errors (TRACEr-rail version), used as the means of identifying and classifying train driver errors associated with rail accidents/incidents in Australia. We aimed to identify the similarities and differences between the techniques in their capacity to identify and classify errors and also to determine how consistently the tools are applied. The HFACS analysis indicated that slips of attention (i.e. ‘skilled based errors’) were the most common ‘unsafe acts’ committed by drivers. The TRACEr-rail analysis indicated that most ‘train driving errors’ were ‘violations’ while most ‘train stopping errors’ were ‘errors of perception’. Both tools identified the underlying factors with the largest impact on driver error to be decreased alertness and incorrect driver expectations/assumptions about upcoming information. Overall, both tools proved useful in categorising driver errors from existing investigation reports, however, each tool appeared to neglect some important and different factors associated with error occurrence. Both tools were found to possess only moderate inter-rater reliability. It is thus recommended that the tools be modified, or a new tool be developed, for complete and consistent error classification.     

煤矿安全管理体系缺失和不安全行为研究

现阶段我国煤矿的安全技术、生产设备都有大幅提高,但事故发生率仍居高不下,其主要原因是安全管理体系的缺失和存在不安全行为。为预防事故的发生,研究煤矿安全管理体系和不安全行为是十分必要的。为此,构建适合分析煤矿安全管理体系缺失和不安全行为的HFACS框架。按照HFACS框架,采用SPSS13.0对515起煤矿伤亡事故发生的原因进行整理分类,运用χ2检验和让步比(OR)分析安全管理体系缺失情况,不安全行为发生的原因,以及两者之间的内在联系。研究结果表明,安全管理体系缺失主要表现在管理文化的缺失和监督不充分,不安全行为主要表现在决策差错和习惯性违规。安全管理体系缺失是导致不安全行为的潜在根本原因。     

铁路安全评价方法的探讨与分析

安全是铁路运输永恒的主题.目前,安全评价已经成为当代安全管理中最有成效的一种方法.从安全评价的角度出发,对影响铁路运输安全的因素进行了分析,得出人的因素是影响铁路运输安全的主要因素.在国内外当前铁路安全评价方法研究的基础上进行了探讨与分析,指出了国内外在研究铁路安全及安全评价上的不同,以及目前研究中还存在的一些问题,对铁路安全评价提出了一些见解.     

Revising HFACS for SMEs in the chemical industry: HFACS-CSMEs

Chemical accidents have occurred frequently in recent years, and most have occurred in small and medium-sized enterprises (SMEs). SMEs in the chemical industry face greater challenges than large enterprises with regard to accident prevention. However, SMEs have been unable to effectively learn from accidents due to the limited resources. The accident causation model is an effective tool to help the analyst learn from accidents. As a systematic accident causation model, the causes classification in the human factors analysis and classification system (HFACS) can match the characteristics of SMEs, but the cause of chemical accidents can be ineffectively identified by HFACS. In this study, HFACS was revised for the SMEs in the chemical industry, mainly consisting of three parts. First, based on the definition of factors in the original HFACS, the extended HFACS framework was obtained, which include 78 manifestations with the characteristics of the chemical accidents. Second, 101 accidents occurring in a SME in the chemical industry from 2012 to 2016 were analyzed though the extended HFACS framework. Finally, a new model, known as the HFACS-CSMEs, was obtained by further revising the manifestations and causes classification according to the statistical results of the accident analysis. HFACS-CSMEs consists of 15 cause factors and 56 manifestations, which can effectually identify and distinguish the causes in chemical accidents. Moreover, the easy-to-understand and statistically acceptable features of HFACS-CSMEs can cater to the SMEs regarding accident analysis. HFACS-CSMEs solves the problem that HFACS cannot be directly applied to chemical accidents and provides new ideas about preventing accidents in SMEs in the chemical industry.     

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.     

Factors contributing to US chemical plant process safety incidents from 2010 to 2020

Process safety incidents can result in injuries, fatalities, environmental impacts, facility damage, downtime & lost production, as well as impacts on a company's and industry's reputation. This study is focused on an analysis of the most commonly reported contributing factors to process safety incidents in the US chemical manufacturing industry. The database for the study contained 79 incidents from 2010 to 2019, partly investigated by the Chemical Safety Board (CSB). To be included in the study, the CSB archive of incident investigations were parsed to include only incidents which occurred at a company classified as 325 in the North American Industry Classification System (NAICS), assigned to businesses that participate in chemical manufacturing. For each incident, all of the identified contributing factors were catalogued in the database. From this list of identified contributing factors, it was possible to name the ‘top three’ contributing factors. The top three contributing factors cited for the chemical manufacturing industry were found to be: design; preventive maintenance; and safeguards, controls & layers of protection. The relationship between these top contributing factors and the most common OSHA citations was investigated as well. The investigation and citation history for NAICS 325 companies in the Occupational Safety & Health Administration (OSHA) citations database was then analysed to assess whether there was any overlap between the top reported contributing factors to process safety events and the top OSHA citations recorded for the industry. A database consisting of the inspection and citation history for the chemical manufacturing industry identified by NAICS code 325 was assembled for inspections occurring between 2010 and 2020 (August). The analysis of the citation history for the chemical manufacturing industry specifically, identified that the list of the top contributing factors to process safety incidents overlapped with the most common OSHA violations. This finding is relevant to industry stakeholders who are considering how to strategically invest resources for achieving maximum benefit – reducing process safety risk and simultaneously improving OSHA citation history.     

铁路事故致因与风险分析

为保障铁路运输安全、预防铁路事故的发生,全面系统地分析各种铁路安全影响因素。基于美国2005年铁路事故的相关统计资料,采用灰色系统理论分析铁路事故致因,确定不同事故类型中各安全影响因素的主次关系;并以蒙特卡罗风险分析方法为基础,运用@Risk软件从人-机-环及时间的角度出发,对各因素的风险概率进行拟合。结果表明:人员-设备因素是导致事故的主要因素,针对人员-设备因素采取适当的预防措施便能有效减少铁路事故的发生。     

矿区铁路安全管理信息系统的研究

针对我国矿区铁路运输安全管理落后的现状,分析矿区铁路运输安全管理的主要特点,设计了矿区铁路安全管理信息系统的总体结构。以徐沛铁路运输系统为例,基于B/S模式开发了徐沛铁路安全管理信息系统,实现了对职工的安全培训考核、职工安全档案管理、运输事故信息的录入与统计分析、各类安全文档的管理、技术措施的审批和安全直通车的功能。该系统已在徐沛铁路运输安全管理中得到成功应用,也可应用于其他矿区铁路安全管理。     

22家企业建立职业健康安全管理体系前后社会和经济效益对比分析

作者抽取已建职业健康安全管理体系的22家企业,对其建立体系前后的企业经营活动、安全生产投入、因事故和职业病的经济投入(损失)进行分析.分析结果表明职业健康安全管理体系的建立和运行对企业有良好的社会和经济效益.     

基于有序Probit模型的铁路险兆事件影响因素识别研究*

为识别铁路险兆事件的影响因素,以宜春车务段2017年9月—2017年10月共1 870条数据为样本,以铁路险兆事件等级为因变量,事件原因、环境特征和事件特征为自变量建立有序Probit模型,探究人、设备、环境和管理因素对铁路险兆事件严重影响程度。研究结果表明:设备设施未按规定防护是影响严重性险兆事件发生的主要因素;与其他人为因素相比,未执行相关作业规定对增加险兆事件严重程度有显著作用。研究结果可为铁路管理部门实现事故预控提供依据。     

Omnidirectional safety culture analysis and discussion for railway industry

On the basis of literature relevant to safety culture and investigation of the Taiwan Occupational Safety and Health Management System (TOSHMS), the Omnidirectional Safety Culture Model (OSCM) was proposed in which a questionnaire composed of 18 safety dimensions was developed and used in safety culture evaluation. This questionnaire was reviewed by a focus group of employees with various backgrounds and was revised accordingly. Questionnaire items were selected and amended by considering the suggestions of experts; the Taiwan railway industry was surveyed as the questionnaire subject; and the current safety culture of the railway industry was extensively investigated. It was determined the railway employees place a higher emphasis on safety awareness and attitude as well as safe behavior, leading to the conclusion that they recognize the importance of safety and value human life over other matters. However, railway employees also believe that procurement management; safety encouragement and punishment; and safety rule have more room for improvement.     

Designing continuous safety improvement within chemical industrial areas

This article provides support in organizing and implementing novel concepts for enhancing safety on a cluster level of chemical plants. The paper elaborates the requirements for integrating Safety Management Systems of chemical plants situated within a so-called chemical cluster. Recommendations of existing Plant Safety Management System Codes of Good Practice are analyzed in relation to the needs of cluster chemical safety. The paper establishes comprehensive guidelines for gradually standardizing Plant Safety Management Systems through the design, the development and the installation of a Cluster Safety Management System within a group of chemical companies. A cluster organization framework is proposed and a scheme for continuously improving cluster and plant safety management via communication and cooperation at plant department level as well as at cluster level is suggested.     

Analysis of fatalities and injuries involving mining equipment

INTRODUCTION: Despite significant reductions, the number of injuries and fatalities in mining remains high. A persistent area of concern continues to be equipment-related incidents. METHOD: Mine Safety and Health Administration (MSHA) and Current Population Survey (CPS) data were used to examine equipment-related injuries over the period 1995-2004. Incidents were reviewed to determine which types of mining equipment were most often involved and to identify and characterize trends. RESULTS: Non-powered hand tools was the equipment category most often involved with non-fatal injuries while off-road ore haulage was the most common source of fatalities. SUMMARY: Younger employees had an elevated risk of injury while workers >55 years had an elevated risk for fatality. A large majority of incidents involve workers with <5 years experience. IMPACT ON INDUSTRY: Results should increase hazard awareness and enable mine management to select and prioritize problem areas and safety system weaknesses in both underground and surface mining.     

An analysis of human factors in fifty controlled flight into terrain aviation accidents from 2007 to 2017

Introduction: Controlled Flight Into Terrain (CFIT) account for a considerable amount of fatalities when compared to other accident categories. Human factors are deemed significant contributory causes in these accidents. This paper aims to identify the human factors involved with aviation accidents that resulted in CFIT. Method: The study used the Human Factors Analysis and Classification System (HFACS) framework to determine the factors involved in 50 CFIT accidents from 24 counties over a 10 year period, i.e. 2007–2017. Interviews with five senior aviation safety experts were used to provide a better comprehension of the human factors affecting the flight safety. Results: The study identified 1289 individual causal and contributory human factors with unsafe actions and preconditions for unsafe actions being the main subcategories of the accidents. The study found that CFIT occur across a range of pilot experience and 44% of accidents occurred in cruise flight. Distraction, complacency and fatigue are all elements that flight crews may experience as contributors to CFIT during cruising. Conclusions: Human factors represent a major component of CFIT accidents. The analysis revealed a similar pattern of contributory and causal human factors across the various flight categories, with some noteworthy isolated variations. The prevalent factors were decision and skill-based errors along with communication, coordination and planning issues. Practical applications: Provision of specific CFIT awareness, pilot training focusing on improved decision-making and revision of basic flight skills, development of specific Global Positioning System routes for transiting high terrain areas are necessary to prevent CFIT accidents. Installation of Terrain Avoidance and Warning System and Ground Proximity Warning System and appropriate equipment training, specific CFIT Crew Resource Management training and improvement of organizational knowledge on the elements involved in CFIT are also recommended.     

面向安全和可持续发展的企业危机管理

企业安全生产事故与环境污染事件极易相互诱发及转化.实现节约发展、清洁发展、安全发展和可持续发展是中国企业发展的政策要求,也是企业应对能源与资源危机的现实选择.本文分析了新形势下建立并运行环境管理体系为企业带来的竞争优势,提出了基于危机生命周期的两种企业危机管理模式,为企业实现面向安全和可持续发展的危机管理实践提供了循序渐进的实施步骤.     

青藏铁路列车运行控制系统的安全性分析

分析了青藏铁路中多种不利因素对轨道电路参数的影响 ;提出了在青藏铁路不宜采用现行基于轨道电路的列车运行控制系统 ,而应选择基于通信的列车运行控制系统的理由 ;给出了系统的基本结构及提高系统可靠性的措施 ;与此同时 ,就人们关心的无线传输列车控制数据的可靠性和安全性难题 ,通过建立马尔可夫模型的方法进行了分析     

Human and organizational factors in Chinese hazardous chemical accidents: a case study of the ‘8.12’ Tianjin Port fire and explosion using the HFACS-HC

Human and organizational factors have been proven to be the prime causes of Chinese hazardous chemical accidents (HCAs). A modified version of the Human Factors Analysis and Classification System (HFACS), namely the HFACS-Hazardous Chemicals (HC), was developed to identify the human factors involved in Chinese HCAs. The ‘8.12’ Tianjin Port fire and explosion, the costliest HCA in recent years, was reanalyzed using this framework, and the results were compared with the official accident inquiry report to determine their differences related to the identification of human and organizational factors. The study revealed that interacting human factors from different levels in Ruihai Company led to this catastrophe, and the inquiry report had limitations in the identification of human factors and the guidance for similar accident prevention. This study showed the applicability of the HFACS-HC in HCA analyses as well as the necessity to recommend this approach for future HCA investigations.     

基于过程方法的企业安全评价指标体系构建方法

针对安全评价技术的应用现状,分析现有安全评价体系在构建上的局限性,认为安全评价体系应基于现代安全管理体系的运作方式进行构建;回顾安全管理的发展过程,对代表现代安全管理的两种管理模式的起源及特点进行了分析,认为两种管理模式都应用了质量管理的过程方法;在该基础之上,结合过程方法的特点与企业的实际运作方式,提出基于过程方法的安全管理模型,并运用该模型,对安全评价体系的指标构成进行分析;以危险源识别、管理过程、安全教育与培训和应急准备与响应4个指标为基础,构建了安全评价体系的框架。     

职业安全健康管理体系对企业经济和社会效益影响研究

为了评估职业安全健康管理体系的建立与企业经济和社会效益的关系 ,笔者对 12 5家企业的安全生产投入 ,因事故、职业病或违约造成的经济投入 (损失 ) ,以及建立职业安全健康管理体系后对企业经营活动及社会形象的影响进行了分析。结果发现 ,企业在建立职业安全健康管理体系期间及之后其安全生产投入比未建企业和建立体系之前增加 ;对事故、职业病或违约造成的经济投入加大 ;签订合同额和投标活动的中标率上升 ,员工抱怨次数及相关方抱怨次数下降。上述结果表明 ,职业安全健康管理体系的建立和运行对企业有良好的经济和社会效益。     

What can the trove of CSB incident investigations teach us? A detailed analysis of information characteristics among chemical process incidents investigated by the CSB

Understanding the commonalities among previous chemical process incidents can help mitigate recurring incidents in the chemical process industry and will be useful background knowledge for designers intending to foster inherent safety. The U.S. Chemical Safety and Hazard Investigation Board (CSB) reports provide detailed and vital incident information that can be used to identify possible commonalities. This study aims to develop a systematic approach for extracting data from the CSB reports with the objective of establishing these commonalities. Data were extracted based on three categories: attributed incident causes, scenarios, and consequences. Seventeen causal factors were classified as chemical indicators or process indicators. Twelve chemical indicators are associated with the hazards of the chemicals involved in the incidents, whereas five process indicators account for the hazards presented by process conditions at the time of the incident. Seven scenario factors represent incident sequences, equipment types, operating modes, process units, domino effects, detonation likelihood for explosion incidents, and population densities. Finally, three consequence factors were selected based on types of chemical incidents, casualties, population densities, and economic losses. Data from 87 CSB reports covering 94 incidents were extracted and analyzed according to the proposed approach. Based on these findings, the study proposes guidelines for future collection of information to provide valuable resources for prediction and risk reduction of future incidents.