Accident in a French dynamite factory: An example of an organisational investigation

The 27th of March 2003, an explosion caused the death of four employees in a Nitrochimie pyrotechnic plant, at Billy Berclau, in the north of France. Following the accident, the ministry of Ecology and Sustainable Development appointed INERIS to perform an investigation. According to the terms of reference, the investigation would cover technical (origins of the explosion, extent of damages) as well as organisational issues, as defined by SEVESO II safety management system requirements. This paper has a threefold purpose. It intends first to illustrate with an empirical case the current trend in safety auditing and accident investigation, targeting organisational factors, alongside human factors. There are not so many published cases of accidents analysed with an organisational perspective. Secondly, it shows that it is possible to investigate organisational dimensions (through articulation of safety engineering, safety management and human and social sciences) within reasonable time frames and a reasonable amount of resources. By focusing on key actors and asking appropriate questions related to key dimensions, investigating organisational accidents might not necessarily imply spending much more resources than other steps such as damage assessment, chronological construction or identification of technical scenarios, although there are also some prerequisite conditions needed to achieve this. Finally this paper should be seen as a technical communication beyond the pyrotechnic industry.     

Human and organisational factors in the operational phase of safety instrumented systems: A new approach

The international standards IEC 61508 and IEC 61511, which provide a general framework for the design and implementation of safety instrumented systems, require quantification of the achieved risk reduction, expressed as a safety integrity level (SIL). Human and organisational factors affect the performance of safety instrumented systems during operation and may threaten the achieved SIL, but this is usually not explicitly accounted for. This article presents a new approach to address human and organisational factors in the operational phase of safety instrumented systems. This approach gives a prediction of the operational SIL and can also be used to improve safety. It shows which human and organisational factors are most in need of improvement and it provides guidance for preventive or corrective action. Finally, the approach can be used as part of a SIL monitoring strategy in order to maintain the achieved SIL at the required level during the operational phase.     

An algorithm for the implementation of safety improvement programs

In production system workplace environments, the achievement of safety objectives depends essentially on the risk assessment process and on the adequacy of measures to eliminate or reduce risk. The main goal of the planning phase is to define in advance the effective management of resources (financial, human and technical) involved in the completion of the overall safety improvement program. Indeed, whereas the results of the risk assessment process depend only on the correct evaluation of the work system with respect to human safety, the planning phase of safety improvement program is subject to economic, technical and organisational constraints and has to be integrated with other company objectives. Within this context, the plan definition should include additional objectives other than risk reduction, such as the clustering of measures with homogenous or compatible characteristics and the minimisation of production system disturbance (inefficiency) over the program time span. However, no safety improvement program can really be implemented if operational constraints (i.e. finite availability of resources, incompatibility in the execution of measures and limited acceptance of inefficiency) are overlooked. The present paper proposes a quantitative view of these objectives and constraints in order to develop an algorithm for the scheduling of measures within a safety improvement program. By means of the evaluation of a priority index, this algorithm provides a plan with the higher rate of risk reduction possible that maximises the objectives in function of their relative importance, obeying the imposed constraints. The definition of the safety improvement program for a textile factory shows how the algorithm can produce a plan with higher rate of risk reduction in comparison with plans based only on risk priority.     

Availability organisational analysis: Is it a hazard for safety?

This main issue of this article analyses the possible way to use for availability improvement, the organisational analysis methodology initially developed for accident safety investigations. As the last decade examples in the industrial world prove that some organisational weaknesses could either impact safety or availability, we have for purpose to make some important clarifications, with the help of the organisational paradigm, and grounded on our knowledge of safety accidents or local inquiries in hazardous technical complex systems.We will first give our definition of an availability event, by comparison with a safety event and recall what is for us an organisational analysis. Then we will consider the safety organisational paradigm pathogenic factors in wondering if these factors could also be seen as pathogenic factors for availability; or if specific availability pathogenic factors can be inferred from these safety pathogenic factors.In the end we will try to assess the common points and the differences between an availability oriented organisational analysis and a safety oriented one, with a particular attention to possible negative follows-up on safety issues and to the methodology issue.     

Perspectives on safety culture

Overviewing selected elements from the literature, this paper locates the notion of safety culture within its parent concept of organisational culture. A distinction is drawn between functionalist and interpretive perspectives on organisational culture. The terms ‘culture’ and ‘climate’ are clarified as they are typically applied to organisations and to safety. A contrast is drawn between strategic top down and data-driven bottom up approaches to human factors as an illustrative aspect of safety. A safety case study is used to illustrate two measurement approaches. Key issues for future study include valid measurement of safety culture and developing methods to adequately represent mechanisms through which safety culture might influence, and be influenced by, other safety factors.     

I-Risk: development of an integrated technical and management risk methodology for chemical installations

This paper presents an integrated quantitative risk assessment method for hazardous installations, taking into account management as well as technical design and producing risk level measures. The key components of the I-Risk methodology are the technical model, the management model and their interface. The technical model consists of developing a master logic diagram (MLD) delineating the major immediate causes of loss of containment (LOC) and associated quantitative models for assessing their frequency. The management model consists of the tasks, which must be carried out systematically in the primary business functions (such as operations, emergency operations, maintenance and modifications). A management audit quantifies the quality of these management tasks. The management–technical interface modifies certain parameters of the technical model on the basis of the quality of the safety management system of the specific installation. The methodology is exemplified through its application to the risk assessment of an ammonia storage facility. A detailed technical model simulating the response of the system to various initiating events is developed along with a detailed management model simulating the influence of the plant-specific management and organisational practices. The overall effect is quantified through the frequency of release of ammonia as a result of a loss of containment in a storage tank and in a pipeline.     

Organisational safety indicators: Some conceptual considerations and a supplementary qualitative approach

This article discusses the extent to which indicators can represent organisational qualities in relation to safety and how a qualitative approach called the Operational Safety Condition (OSC) method can be a supplement and help improve safety. In light of the recent Safety Science debate on safety indicators, we suggest that it is difficult to capture organisational conditions using indicators, although they are indisputably important when identifying the risk of accidents. Safety climate and risk analysis approaches are discussed as methods that can build and assess indicators in relation to organisational safety quality. OSC and similar qualitative approaches can capture the complexity of organisational conditions, aid organisational learning at a double loop level and offer a tool for risk management.     

基于个人数字助理(PDA)的安全管理移动办公信息系统设计

为了提高安全管理效率、有效解决现场决策困难问题以及规范执法程序,设计了以VB.NET作为开发语言、WINCE.NET作为运行环境、SQL作为后台支持数据库的基于PDA的安全管理移动办公信息系统。该系统结合安全管理工作特性和现场安全管理信息需求,充分发挥掌上电脑的便携以及方便用户进行二次开发的优势,构建了安全管理、执法监察、危管通等9个功能模块,并能结合企业版和管理版两种版本的后端支持平台进行数据通讯。应用实践表明,该系统是实现安全管理信息化,提升安全管理水平的重要技术手段。     

基于ArcIMS的高校安全管理与救援辅助WebGIS开发

近年来国内高校屡屡发生各类突发公共安全事件,给高校校园公共安全管理工作带来了巨大压力和挑战。为寻求解决高校安全管理问题的有效手段、切实提高高校安全管理能力和技术水平,文章在阐述WebGIS技术应用于校园安全管理的可行性、必要性和优越性,以及ArcIMS和ArcSDE的体系结构、原理及技术优势的基础上,提出构建一种基于ArcIMS平台开发的高校安全管理与救援辅助WebGIS系统。对系统开发目标、开发环境以及主要功能组成作了详细的设计与配置,给出了运用ArcSDE和SQL Server2K集中存储校园安全管理空间和属性数据的技术方案,实现了以Internet为依托进行校园安全管理和可视化救援方案网上发布的目标。其中利用ArcIMS中的协作GIS概念和工具实现救援方案的编辑与决策是本系统的特色之处。     

Assessment of selected safety performance evaluation methods in regards to their conceptual,methodological and practical characteristics

The evolution of safety performance evaluation, from incident-based to prospective and recently to holistic approaches, follows the similar evolutionary path of accident causation and safety management. Holistic approaches are characterized by an integrated use of technical, organisational and human factors for the development of safety performance indicators. The aim of this paper is to propose a set of assessment criteria for safety performance evaluation methods which will also give emphasis to their holistic nature. Specific criteria related to conceptual, methodological and practical characteristics of the methods have been initially selected and six safety performance evaluation methods are evaluated in a trial implementation of these criteria. Results indicate that the proposed criteria can be applied in different types of safety performance evaluation methods in order to extract useful information in regards to their holistic character as well as to their appropriateness and usefulness.     

Studying organisational cultures and their effects on safety

How do organisational cultures influence safety? To answer this question requires a strategy for investigating organisational culture. By far the most widely used research strategy is the perception survey. An alternative is for researchers is to immerse themselves in one or more organisations, making detailed observations about activities and drawing inferences about the nature of the organisation’s culture (the ethnographic method). A third technique makes use of the wealth of material that is assembled by inquiries into major accidents. This paper describes how this material can be used to provide insights into organisational cultures. It draws on specific examples from the author’s own work as well as the cultural analysis carried out by the Columbia Accident Investigation Board. It concludes with some additional suggestions for carrying out research on safety-relevant aspects of organisational culture.     

Can focus on safety culture become an excuse for not rethinking design of technology?

Two generic organisational contexts associated with technological designs in relation to safety culture are discussed: (1) operating organisations using existing technologies, and (2) design organisations as producers of technologies. It is argued that the concept of safety culture, if misused, may lead to the adoption of non-effective change strategies in the operational context. On the other hand, it is also argued that design organisations should invest more attention to issues commonly subsumed under the concept of safety culture. In this case, however, the concept of safety culture has to be adapted to fit the demands facing design organisations. Issues of morality and their association with the safety culture concept will be discussed. It is suggested that a stronger focus on understanding innovation and safety together should nourish future research about culture’s influence on design and safety.     

Recognition primed decision making and the organisational response to accidents: Überlingen and the challenges of safety improvement in European air traffic management

The pioneering work of Rasmussen, Reason and their colleagues has greatly improved our understanding of the longer term causes of adverse events in safety-critical systems. Far less attention has been paid to the organisational decision making that characterises the response to accidents and incidents. Therefore, this paper examines the interventions by national and international agencies after one of the most serious accidents in European Air Traffic Management. Insights from Naturalistic Decision Making (NDM) and Recognition Primed Decision Making (RPDM) are used to explain the complex ways in which technical, organisational and political constraints shape and support the decisions and actions taken by different agencies. These constraints affect national and international safety organisations in the aftermath of major accidents. In particular, this paper uses NDM and RPDM to assess the interventions made by Swiss Federal agencies and by the Air Navigation Service provider (ANSP) following the Überlingen mid-air collision in July 1st 2002. Later sections show that there are strong similarities between the technical, organisational and political constraints that informed their decisions and the factors that directed the work of the European Organisation for the Safety of Air Navigation (EUROCONTROL). Some of EUROCONTROL’s safety responsibilities (i.e. the safety regulation elements) will in the future pass to the European Aviation Safety Agency (EASA), an Agency of the European Commission. This transfer of responsibilities has the potential to increase the powers available to ensure the implementation of recommendations following future accidents. At the same time there is a danger that key aspects of existing safety and regulatory activities may be overlooked. It is critical, therefore, that the same level of audit and monitoring be conducted on the European agencies during the transition period as is proposed for service providers and national regulatory agencies. It is important to ensure that these changes do not inadvertently lead to the loss of insights from previous adverse events.     

本质安全化管理思想及实证研究框架

分析国内本质安全化管理研究现状及存在问题,指出两类系统本质安全化实现路径的差异性:①技术系统本质安全性等于构成要素的本质安全性乘积,只要保证要素本质安全化,系统也趋于本质安全化;②社会技术系统关键要素是智能体,从根本上无法达到本质安全化,但智能体自身具有一定容错性和自组织性,在相对可靠条件下,需要通过和谐交互机制使系统而获得本质安全化。分析和研讨的基础上,提出交互式安全管理理论的本质安全化管理研究基本思路:基于3层次和谐交互机制的本质安全化动态演化机制;并对系统本质安全化进行了量化;给出判定系统能否实现本质安全化条件以及本质安全化管理的基本函数关系;得出了系统本质安全化是系统安全性极限的结论。     

基于AHP-CRITIC的电梯安全性评估

针对电梯安全评估方法中指标权重主观性大的问题,为提高评估结果的科学性,综合AHP法、CRITIC法和模糊综合评价理论,建立了电梯安全性评估模型。从设备情况、使用情况、人员管理3个方面出发,构建了电梯安全性评估指标体系。采用AHP法,根据专家经验构造判断矩阵,得到指标的主观权重。采用CRITIC法,计算同一指标的对比强度和指标间的冲突性,得到指标的客观权重。通过加权求和的方式,兼顾主客观权重,得到指标的综合权重。基于模糊综合评价法,应用"升半梯形分布"对各级指标构造模糊评估矩阵,并量化评估结果向量。以南京市某电梯为实例,应用该模型得出此电梯的安全值为68.8,安全等级为"较安全",与此电梯的实际情况相符;并与其他方法所得的评估结果进行比较,进一步验证了该模型的正确性和有效性。     

基于集值统计-灰色模糊的航道通航环境安全评价

鉴于航道通航环境安全评价的模糊性和随机性,结合集值统计法和灰色模糊理论,建立航道通航环境安全评价模型。在综合分析航道通航环境安全影响因素的基础上,建立了由自然环境、航道条件、交通环境3类一级指标及12项二级指标所组成的航道通航环境安全评价指标体系。该模型利用集值统计确定各个评价指标的权重;通过确定评价样本矩阵,实现对航道通航环境场景的初步构建;利用灰色模糊综合评价法,量化评估航道通航环境安全等级。以广东坭洲头航道为例进行实例分析,结果表明,基于集值统计和灰色模糊理论的安全评价方法计算简单,评价结果客观、准确,便于实际应用。     

医院安全保障中的技术因素

医院安全保障体系的技术构成包括安全的诊疗救护技术、后勤供养技术和安全保卫技术。其技术特点是以人为本 ,服务健康 ,应急性强 ,发展迅速 ,互相影响。本文提出了医院安全保障体系改革的构想和建立医院安全保障体系中应考虑的技术因素。     

The nature of safety culture: a review of theory and research

This paper reviews the literature on safety culture and safety climate. The main emphasis is on applied research customary in the social psychological or organisational psychological traditions. Although safety culture and climate are generally acknowledged to be important concepts, not much consensus has been reached on the cause, the content and the consequences of safety culture and climate in the past 20 years. Moreover, there is an overall lack of models specifying either the relationship of both concepts with safety and risk management or with safety performance. In this paper, safety culture and climate will be differentiated according to a general framework based on work by Schein (1992 Schein) on organisational culture. This framework distinguishes three levels at which organisational culture can be studied — basis assumptions, espoused values and artefacts. At the level of espoused values we find attitudes, which are equated with safety climate. The basic assumptions, however, form the core of the culture. It is argued that these basic assumptions do not have to be specifically about safety, although it is considered a good sign if they are. It is concluded that safety climate might be considered an alternative safety performance indicator and that research should focus on its scientific validity. More important, however, is the assessment of an organisation's basic assumptions, since these are assumed to be explanatory to its attitudes.     

航运公司安全管理有效性组合赋权评价模型

为提高航运公司安全营运管理的决策科学性,需要对其安全营运管理的有效性进行过程跟踪评价。基于安全管理的运行过程与安全结果 2种评估指标,提出2种指标相结合的安全管理有效性评价模型。在熵权法(EVM)和层次分析法(AHP)计算的基础上,通过一致性检验确定有效性评价体系指标的权重。提出以组合赋权法确定优化权重数值。经案例应用,得出某航运公司安全管理有效性评价定量化结果。分析结果表明,当前该公司安全管理体系中操作管理是安全管理绩效的关键,而人力资源方面和管理体系方面的改善措施需要与之协调。