Evidence-based safety (EBS) management: A new approach to teaching the practice of safety management (SM)

Introduction: In safety management (SM), it is important to make an effective safety decision based on the reliable and sufficient safety-related information. However, many SM failures in organizations occur for a lack of the necessary safety-related information for safety decision-making. Since facts are the important basis and foundation for decision-making, more efforts to seek the best evidence relevant to a particular SM problem would lead to a more effective SM solution. Therefore, the new paradigm for decision-making named “evidence-based practice (EBP)” can hold important implications for SM, because it uses the current best evidence for effective decision-making. Methods: Based on a systematic review of existing SM approaches and an analysis of reasons why we need new SM approaches, we created a new SM approach called evidence-based safety (EBS) management by introducing evidence-based practice into SM. Results: It was necessary to create new SM approaches. A new SM approach called EBS was put forward, and the basic questions of EBS such as its definition and core were analyzed in detail. Moreover, the determinants of EBS included manager's attitudes towards EBS; evidence-based consciousness in SM; evidence sources; technical support; EBS human resources; organizational culture; and individual attributes. Conclusions: EBS is a new and effective approach to teaching the practice of SM. Of course, further research on EBS should be carried out to make EBS a reality. Practical applications: Our work can provide a new and effective idea and method to teach the practice of SM. Specifically, EBS proposed in our study can help safety professionals make an effective safety decision based on a firm foundation of high-grade evidence.     

The relationship between cell phone use and management of driver fatigue: It's complicated

Introduction: Voice communication may enhance performance during monotonous, potentially fatiguing driving conditions (Atchley & Chan, 2011); however, it is unclear whether safety benefits of conversation are outweighed by costs. The present study tested whether personalized conversations intended to simulate hands-free cell phone conversation may counter objective and subjective fatigue effects elicited by vehicle automation. Method: A passive fatigue state (Desmond & Hancock, 2001), characterized by disengagement from the task, was induced using full vehicle automation prior to drivers resuming full control over the driving simulator. A conversation was initiated shortly after reversion to manual control. During the conversation an emergency event occurred. Results: The fatigue manipulation produced greater task disengagement and slower response to the emergency event, relative to a control condition. Conversation did not mitigate passive fatigue effects; rather, it added worry about matters unrelated to the driving task. Conversation moderately improved vehicle control, as measured by SDLP, but it failed to counter fatigue-induced slowing of braking in response to an emergency event. Finally, conversation appeared to have a hidden danger in that it reduced drivers' insights into performance impairments when in a state of passive fatigue. Conclusions: Automation induced passive fatigue, indicated by loss of task engagement; yet, simulated cell phone conversation did not counter the subjective automation-induced fatigue. Conversation also failed to counter objective loss of performance (slower braking speed) resulting from automation. Cell phone conversation in passive fatigue states may impair drivers' awareness of their performance deficits. Practical applications: Results suggest that conversation, even using a hands-free device, may not be a safe way to reduce fatigue and increase alertness during transitions from automated to manual vehicle control.     

教练直升机训练系统安全评价研究

为保证教练直升机的使用安全,预防事故发生,针对当前教练直升机安全风险决策数据量少、存在模糊的特点,提出基于模糊D-S证据理论的教练直升机训练系统安全评价模型。从人-机-环-管4个系统出发,建立教练直升机训练系统安全评价指标体系,运用模糊评价技术评估教练直升机系统安全影响因素,利用D-S证据理论的层次递归算法对不同层次影响因素的评估等级进行合成,并以某型教练直升机为例,给出评价步骤。结果表明:该方案适用于研究教练直升机训练系统安全评价;根据安全性量化值,能够实现按安全性能优劣对系统的快速排序。     

The challenge of collective learning from event analysis

This paper examines the difficulties of learning from event analysis. The central idea is that learning represents a distinct set of team-or unit-level outcomes and processes that is different from valid analysis, effective problem-solving, or individual learning. In other words, event analysis cannot automatically generate group learning. For learning to occur, several conditions must be satisfied: Change in the team’s or unit’s repertoire of behaviors (the learning) must be a clear outcome of the event analysis; this learning must be shared by the team members (i.e., members must become aware of both the content of the learning as well as of the fact that other members are aware of this learning); the shared learning must be stored in repositories for future retrieval; the stored learning must be retrieved when the team subsequently encounters situations where the learning is relevant; and, finally, these processes of sharing, storing, and retrieving the learning must continue to occur over an extended period of time. These requirements pose major dilemmas or challenges for learning from event analysis. We discuss these challenges using examples from event analysis teams in two hospitals and in a computer emergency response center. We offer some potential strategies for addressing these challenges.     

Safety in high-risk helicopter operations: The role of additional crew in accident prevention

ObjectivesTo examine the causes associated with high risk helicopter operations, in particular external load and aerial application flight, and determine the role of crew management in accident mitigation strategies.MethodsData from the US National Transportation Safety Board online database were analyzed. Flight phases and types of rotor strike were added categories extracted from the narrative statements included in the accident reports.Results and recommendationsAerial application and external load accidents are characterized by high numbers of rollovers, rotor strikes and errors during preflight checks. Additional flight or ground crew may assist the pilot in maintaining a visual lookout. The number of accidents can be further reduced with adequate fuel management in which both pilot and ground crew can contribute. Although the ground crew can be both victim and cause of an accident, their supporting role has much to contribute to safety in high risk helicopter operations.     

直升机蒸气循环制冷系统技术现状与展望

笔者主要从舱内环境控制方面 ,分析了高温对直升机飞行安全的影响 ,指出了直升机安装制冷系统的必要性 ,同时对国外现役直升机采用的两种制冷系统即蒸气循环制冷系统与空气循环制冷系统进行了性能对比。在此基础上 ,提出我国发展直升机制冷系统的主推方案是蒸气循环制冷系统 ,并对我国进行直升机蒸气循环制冷系统研究的技术关键和发展方向给予展望 ,为我国开展此领域的科学研究和技术创新提供一定的技术储备。     

Lithium ion battery energy storage systems (BESS) hazards

There has been an increase in the development and deployment of battery energy storage systems (BESS) in recent years. In particular, BESS using lithium-ion batteries have been prevalent, which is mainly due to their power density, performance, and economical aspects. BESS have been increasingly used in residential, commercial, industrial, and utility applications for peak shaving or grid support. As the number of installed systems is increasing, the industry has also been observing more field failures that resulted in fires and explosions. Lithium-ion batteries contain flammable electrolytes, which can create unique hazards when the battery cell becomes compromised and enters thermal runaway. The initiating event is frequently a short circuit which may be a result of overcharging, overheating, or mechanical abuse. During the exothermic reaction process (i.e., thermal runaway), large amounts of flammable and potentially toxic battery gas will be generated. The released gas largely contains hydrogen, which is highly flammable under a wide range of conditions. This may create an explosive atmosphere in the battery room or storage container. As a result, a number of the recent incidents resulted in significant consequences highlighting the difficulties on how to safely deal with the hazard. This paper identifies fire and explosion hazards that exist in commercial/industrial BESS applications and presents mitigation measures. Common threats, barriers, and consequences are conceptually shown and how they would be identified in a hazard mitigation analysis (HMA). Mitigation measures that can be implemented to reduce the risk of a fire or an explosion are discussed. The presented information is intended to provide practical information to professionals and authorities in this fairly new industry to assure that prevention and mitigation strategies can be effectively implemented and that the regulatory requirement of the HMA can be met.     

Subjective theories of organizing and learning from events

The present paper outlines potential shortcomings of analyzing events in high hazard systems. We argue that the efficiency of organizational learning within high hazard systems is at least partially undermined by the subjective theories of organizing held by their members. These subjective theories basically reflect an “engineering” understanding of “how a system and its components perform”, and are assumed to involve (social-) psychological blind spots when applied to the analysis of events. More specifically, we argue that they neglect individual motives and goals that critically drive work performance and social interactions in high hazard systems. First, we focus on the process of identifying the causes of failed organizing within the course of an event analysis. Our analysis reveals a mismatch between the basic functional assumptions of the event analyst on the motives of social actors involved in an event and on the other hand, the perspective held by the social actors themselves. Second, we discuss the process of correcting failed social system performance after events. Thereby we draw on blind spots that emerge from the direct application of technical safety principles (i.e., standardization and redundancy) to the organization of social systems. Finally, we propose some future research strategies for developing event analysis methods which are aimed at improving an organization’s learning potential.     

Assessing drivers' response during automated driver support system failures with non-driving tasks

IntroductionWith the increase in automated driver support systems, drivers are shifting from operating their vehicles to supervising their automation. As a result, it is important to understand how drivers interact with these automated systems and evaluate their effect on driver responses to safety critical events. This study aimed to identify how drivers responded when experiencing a safety critical event in automated vehicles while also engaged in non-driving tasks.MethodIn total 48 participants were included in this driving simulator study with two levels of automated driving: (a) driving with no automation and (b) driving with adaptive cruise control (ACC) and lane keeping (LK) systems engaged; and also two levels of a non-driving task (a) watching a movie or (b) no non-driving task. In addition to driving performance measures, non-driving task performance and the mean glance duration for the non-driving task were compared between the two levels of automated driving.ResultsDrivers using the automated systems responded worse than those manually driving in terms of reaction time, lane departure duration, and maximum steering wheel angle to an induced lane departure event. These results also found that non-driving tasks further impaired driver responses to a safety critical event in the automated system condition.ConclusionIn the automated driving condition, driver responses to the safety critical events were slower, especially when engaged in a non-driving task.Practical applicationTraditional driver performance variables may not necessarily effectively and accurately evaluate driver responses to events when supervising autonomous vehicle systems. Thus, it is important to develop and use appropriate variables to quantify drivers' performance under these conditions.     

Identification, analysis and dissemination of information on near misses: A case study in the construction industry

Near misses are well-known for providing a major source of useful information for safety management. They are more frequent events than accidents and their causes may potentially result in an accident under slightly different circumstances. Despite the importance of this type of feedback, there is little knowledge on the characteristics of near misses, and on the use of this information in safety management. This article proposes guidelines for identifying, analyzing and disseminating information on near misses in construction sites. In particular, it is proposed that near misses be analyzed based on four categories: (a) whether or not it was possible to track down the event; (b) the nature of each event, in terms of its physical features (e.g. falling objects); (c) whether they provided positive or negative feedback for the safety management system; and (d) risk, based on the probability and severity associated with each event. The guidelines were devised and tested while a safety management system was being developed in a healthcare building project. The monitoring of near misses was part of a safety performance measurement system. Among the main results, a dramatic increase in both the number and quality of reports stands out after the workforce was systematically encouraged to report. While in the first 4 months of the study – when the workforce was not encouraged to report – there were just 12 reports, during the subsequent 4 months – when the workforce was so encouraged – there were 110 reports, all of them being analyzed based on the four analytical categories proposed.     

视觉记忆型次任务对驾驶绩效及安全的影响

为研究视觉记忆型次任务对驾驶绩效及安全的影响,采用对未知内容的记忆任务和对已知内容的再认任务分别表征工作记忆和长时记忆过程,构建多组不同难度的次任务,基于标准换道试验环境LCT进行双任务研究。提取并分析驾驶人执行不同任务时车道保持、换道控制等指标的差异以及次任务绩效,基于主客观数据构建综合评判模型。结果表明:双任务驾驶条件下,车辆平均路径偏差、方向盘平均转向角、车道偏移次数指标增大,正确换道比例减小,感知负荷增大,总绩效下降。困难工作记忆组与简单工作记忆组相比,随着任务难度增大,换道控制绩效下降,感知负荷增大,总绩效下降36.1%;困难再认组与工作记忆组相比,车道保持绩效、换道控制绩效提高,感知负荷下降,总绩效提高50%;简单再认组与工作记忆组相比,总绩效变化不大;困难工作记忆组综合绩效最低。上述结果说明:随着次任务难度增大,总绩效下降,但将对未知内容的工作记忆过程转化为对已知内容的再认过程时,总绩效明显提升,这一特点在任务难度较大时更为显著。     

直升机电力作业非线性动态安全评价模型

为有效提高直升机电力作业安全评价能力,落实通用航空作业标准化和规范化管理,本文以直升机电力作业中人员因素、直升机设备因素、电力作业设备因素、自然环境因素、机场环境因素、组织因素、规章管理因素7个模块为一级指标建立安全评价指标体系。结合多位专家给出的概率语义值,基于模糊集与改进的证据融合理论量化各指标风险程度,同时采用三角模糊数法确定中间节点条件概率,最后利用贝叶斯网络模型灵活推理能力,提出直升机电力作业非线性动态安全评价模型。通过对某通用航空公司直升机电力作业安全状况评价分析可知,企业组织因素、电力作业设备因素以及人员因素为主要薄弱环节,需加强管理,可通过提高从业人员的安全防范意识、提高设备可靠性以及加强人员培训等措施对风险进行预防。     

Engineering for Sustainable Development (ESD) in Bio-Diesel Production

Engineering for sustainable development (ESD) is an integrated systems approach, which aims at developing a balance between the requirements of the current stakeholders without compromising the ability of the future generations to meet their needs. This is a multi-criteria decision-making process that involves the identification of the most optimal sustainable process, which satisfies economic, ecological, social criteria as well as safety and health requirements. Certain difficulties are encountered when ESD is applied such as ill-defined criteria, scarcity of information, lack of process-specific data, metrics and the need to satisfy multiple decision makers. To overcome these difficulties ESD can be broken down into three major steps, starting with the life cycle assessment (LCA) of the process, followed by generation of non-dominating alternatives, and finally selecting the most sustainable process by employing an analytic hierarchical selection process. This methodology starts with the prioritization of the sustainability metrics (health and safety, economic, ecological and social components). Then the alternatives are subjected to a pair-wise comparison with respect to each Sustainable Development (SD) indicator and prioritized depending on their performance. The SD indicator priority score and each individual alternative's performance score together are used to determine the most sustainable alternative. In this paper, the analysis approach and metrics for ESD are applied to bio-diesel production.     

Consequence risk analysis using operating procedure event trees and dynamic simulation

Faults due to human errors cost the petrochemical industry billions of dollars every year and can have adverse environmental consequences. Unquantified human error probabilities exist during process state transitions performed each day by process operators using standard operating procedures. Managing the risks associated with operating procedures is an essential part of managing the overall safety risk. Additional operator training and safety education cannot eliminate all such faults due to human errors; therefore, we propose an operating procedure event tree (OPET) like analysis with branches and events specifically designed to perform risk analysis on operating procedures. The OPET method adapts event trees to analyze the risk due to human error while performing operating procedures. We consider human error scenarios during the procedure and determine the likely consequences by applying dynamic simulation. The modified event tree provides an estimate of the error frequencies.Operating procedure steps were developed, and potential operator faults were determined for two typical equipment switching procedures found in chemical plant operations. Then, dynamic simulation using Aspen HYSYS software was applied to determine the overpressure related consequences of each fault. Finally, the error frequencies resulting from those scenarios were analyzed using operating procedure event trees. We found that a typical ethylene plant gas header would overpressure with 0.6% frequency per manual dryer switch. Since dryer switches occur from every few days up to once per shift, these results suggest that dryer switching should be automated to ensure safe and environmentally friendly operation. Process dryer switching performed manually by operators opening and closing gate valves can be automated with control valves and a distributed control system. A sample distillation column was found to overpressure with 0.85% frequency per manual reflux pump switch.     

The social effects of punishment events: the influence of violator past performance record and severity of the punishment on observers' justice perceptions and attitudes

This study examined how the perceptions and attitudes of third party observers of punishment events are influenced by characteristics of the violator and the punishment event itself. Using a scenario methodology, we manipulated the past performance record of the violator and the severity of the consequences administered by the supervisor. Subjects read the scenarios from the point of view of a coworker/ observer, and responded to questions measuring their perceptions of retributive justice and fairness of the punishment, as well as their desire for more punishment, their attitudes toward the supervisor, and their intention to leave the organization. Results showed that observers judged violators with poor performance records as more deserving of punishment than those with good records, and judged events as more fair when the manager's response was severe. Interactions between these two factors were also found to be significant. Implications of these findings are discussed. © 1998 John Wiley & Sons, Ltd.     

Maternal employment experiences,attention problems and behavioral performance: A mediational model

The present study posits and empirically tests a process model examining the effects of interrole conflict, satisfaction with, and commitment to the role of employed mother on a self-report measure of cognitive difficulties and a behavioral measure relevant to work performance (proof reading). Fifty-three full-time employed mothers with at least one child living at home participated. The proposed model, tested using Lisrel VI, provided an excellent fit to the data. Specifically, interrole conflict exerted an indirect effect on proof reading performance, mediated by self-reported attention and concentration difficulties. Satisfaction with and commitment to the role of employed mother were not related to either proof reading performance or self-reported cognitive difficulties.     

部队防化救援装备现状及其发展趋势

本文基于我国化学事故多发,面临着严峻的形势,介绍了部队在处置化学事故时承担的主要任务,以及解放军、公安消防部队和武警部队防化救援装备的现状,并对其趋势进行了展望。     

Effects of multitasking on operator performance using computational and auditory tasks

This study investigated the effects of multiple cognitive tasks on human performance. Twenty-four students at North Carolina A&;T State University participated in the study. The primary task was auditory signal change perception and the secondary task was a computational task. Results showed that participants' performance in a single task was statistically significantly different from their performance in combined tasks: (a) algebra problems (algebra problem primary and auditory perception secondary); (b) auditory perception tasks (auditory perception primary and algebra problems secondary); and (c) mean false-alarm score in auditory perception (auditory detection primary and algebra problems secondary). Using signal detection theory (SDT), participants' performance measured in terms of sensitivity was calculated as ?0.54 for combined tasks (algebra problems the primary task) and ?0.53 auditory perceptions the primary task. During auditory perception tasks alone, SDT was found to be 2.51. Performance was 83% in a single task compared to 17% when combined tasks.     

Effects of external and internal interruptions on boredom at work: two studies

It is proposed that attentional difficulties are central to the experience of boredom. Events which disrupt attention during task performance may contribute to feelings of boredom with the task. Two sources of disruption are explored: external interruptions from the physical environment, and internal interruptions in the form of non-task-related thoughts about current concerns. Study 1 found that external interruptions reduced boredom on a simple task which required little attention, but contrary to expectations, had no impact on reactions to a simple task that did require attention or on reactions to a complex task. Study 2 manipulated internal interruptions via a role-playing methodology, and found that observers attributed greater boredom and less satisfaction to performers who were more frequently interrupted by non-task-related thoughts while at work, especially when these thoughts were about non-urgent concerns. The concepts of internal and external interruptions may be quite useful in understanding variations in the day-to-day experience of work, and in the relationship of non-work to work spheres of life. © 1998 John Wiley & Sons, Ltd.     

Attitude and behaviour of junior rugby union players towards tackling during training and match play

The tackle event in rugby, places both ball-carrier and tackler at a high risk of injury at all levels of play. To reduce this risk of injury, risk factors need to be identified. Attitude and behaviour have been identified as risk factors for injury in other sports, and probably also have a role in rugby. The purpose of this study was to assess the attitude and behaviour of players in training and match play with regards to safety and performance. A questionnaire was designed to assess attitude (importance) and behaviour (frequency and quantity) among junior (under 19) players on a 5-point Likert Scale. Questionnaires were handed out to 220 players (10 schools) at a tournament and 75% (9 schools, n = 164) were returned for analysis. During training and match play, players’ mean ratings were higher for improving performance than for injury prevention. However, a level of importance was evident for injury prevention. When executing a tackle the aim is to dominate the contact situation and prevent the ball-carrier from gaining territory and retaining the ball. Therefore, players, coaches and administrators need to find the most suitable balance between injury prevention and performance during training within their team setting. This process may be facilitated by modifying the current equipment and training drills used to train the tackle, and the time of season during which tackle technique training occurs. Equally important, players should learn proper tackle technique at a younger age, with the importance of safety emphasised from all information sources.