The use of proactive risk management to reduce emergency service vehicle crashes among firefighters

IntroductionEmergency service vehicle crashes (ESVCs), including rollovers and collisions with other vehicles and fixed objects, are a leading cause of death among U.S. firefighters. Risk management (RM) is a proactive intervention to identifying and mitigating occupational risks and hazards. The goal of this study was to assess the effect of RM in reducing ESVCs. Methods: Three fire departments (A, B and C), representing urban and suburban geographies, and serving medium to large populations, participated in facilitated RM programs to reduce their ESVCs. Interventions were chosen by each department to address their department-specific circumstances and highest risks. Monthly crash rates per 10,000 calls were calculated for each department an average of 28 months before and 23 months after the start of the RM programs. Interrupted time series analysis was used to assess the effect of the RM programs on monthly crash rates. Poisson regression was used to estimate the number of crashes avoided. Economic data from Department A were analyzed to estimate cost savings. Results: Department A had a 15.4% (P = 0.30) reduction in the overall monthly crash rate immediately post-RM and a 1% (P = 0.18) decline per month thereafter. The estimated two-year average cost savings due to 167 crashes avoided was $253,100 (95%CI= $192,355 – $313,885). Department B had a 9.7% (P = 0.70) increase in the overall monthly crash rate immediately post-RM and showed no significant changes in their monthly crash rate. Department C had a 28.4% (P = 0.001) reduction in overall monthly crash rate immediately post-RM and a 1.2% (P = 0.09) increase per month thereafter, with an estimated 122 crashes avoided. Conclusions: RM programs have the potential to reduce ESVCs in the fire service and their associated costs; results may vary based on the interventions chosen and how they are implemented. Practical applications: Risk management may be an effective and broadly implemented intervention to reduce ESVCs in the US fire service.     

Implementing risk management to reduce injuries in the U.S. Fire Service

IntroductionRisk management, a proactive process to identify and mitigate potential injury risks and implement control strategies, was used to reduce the risk of occupational injury in a fire department. The objective of this research was to study the implementation of the risk management process for future replication. A second objective was to document changes in fire personnel's knowledge, attitudes, and behaviors related to the selected control strategies that were implemented as part of the risk management process.MethodA number of control strategies identified through the risk management process were implemented over a 2-year period beginning in January 2011. Approximately 450 fire personnel completed each of the three cross-sectional surveys that were administered throughout the implementation periods. Fire personnel were asked about their awareness, knowledge, and use of the control strategies.ResultsFire personnel were generally aware of the control strategies that were implemented. Visual reminders (e.g., signage) were noted as effective by fire personnel who noticed them. Barriers to use of specific control strategies such as new procedures on the fireground or new lifting equipment for patient transfer included lack of knowledge of the new protocols, lack of awareness/access to/availability of the new equipment, and limited training on its use. Implementation challenges were noted, which limited self-reported adherence to the control strategies.ConclusionsFire personnel generally recognized the potential for various control strategies to manage risk and improve their health and safety; however, implementation challenges limited the effectiveness of certain control strategies. The study findings support the importance of effective implementation to achieve the desired impacts of control strategies for improving health and safety.Practical applicationsEmployees must be aware of, have knowledge about, and receive training in safety and health interventions in order to adopt desired behaviors.     

Dynamic approach to risk management: Application to the Hoeganaes metal dust accidents

Several major accidents caused by metal dusts were recorded in the past few years. For instance, in 2011, three accidents caused by iron dust killed five workers at the Hoeganaes Corp. facility in Gallatin, Tennessee (USA). In order to prevent such accidents, a dynamic approach to risk management was defined in this study. The method is able to take into account new risk notions and early warnings and to systematically update the related risk. It may be applied not only in the design phase of a system, but also throughout the system lifetime as a support to a more precise and robust decision making process. The synergy of two specific techniques for hazard identification and risk assessment was obtained: the Dynamic Procedure for Atypical Scenarios Identification (DyPASI) and the Dynamic Risk Assessment (DRA) methods. To demonstrate its effectiveness, this approach was applied to the analysis of Gallatin metal dust accidents. The application allowed collecting a number of risk notions related to the plant, equipment and materials used. The analysis of risk notions by means of this dynamic approach could have led to enhanced hazard identification and dynamic real-time risk assessment. However, the approach described is effective only if associated to a proper safety culture, in order to produce an appropriate and robust decision making response to emerging risk issues.     

Fuzzy logic-based approach for identifying the risk importance of human error

In the system reliability and safety assessment, the focuses are not only the risks caused by hardware or software, but also the risks caused by “human error”. There are uncertainties in the traditional human error risk assessment (e.g. HECA) due to the uncertainties and imprecisions in Human Error Probability (HEP), Error-Effect Probability (EEP) and Error Consequence Severity (ECS). While fuzzy logic can deal with uncertainty and imprecision. It is an efficient tool for solving problems where knowledge uncertainty may occur. The purpose of this paper is to develop a new Fuzzy Human Error Risk Assessment Methodology (FHERAM) for determining Human Error Risk Importance (HERI) as a function of HEP, EEP and ECS. The modeling technique is based on the concept of fuzzy logic, which offers a convenient way of representing the relationships between the inputs (i.e. HEP, EEP, and ECS) and outputs (i.e. HERI) of a risk assessment system in the form of IF–THEN rules. It is implemented on fuzzy logic toolbox of MATLAB using Mamdani techniques. A case example is presented to demonstrate the proposed approach. Results show that the method is more realistic than the traditional ones, and it is practicable and valuable.     

Occupational exposure to human immunodeficiency virus (HIV)--how can we reduce the risk?

We analyzed occupational exposure to potentially infectious body fluids among health care workers (HCWs). Nurses were the most common exposed category of HCWs. In 73.6% cases needle sticks had been the reason of exposure. Recapping a needle was the cause of exposure in 6.9% accidents. Among 189 registered HCWs, 66 (34.9%) performed invasive procedures without any personal protective equipment. Prophylaxis with antiretroviral drugs was necessary in 43 (22.8%) cases. As many as 60.3% of exposure incidents to potentially infectious material result from non-compliance with the relevant recommendations. Continuous education and training is critically needed to prevent occupational exposure to blood-borne infections among health care workers.     

基于人因失误分析的医院电气安全管理研究

医院是重点用电单位,用电的安全性和供电可靠性都比较高,但因不可抗力、供电系统故障、医院管理问题、人为失误等方面的原因,仍存在发生各类电气突发事件的风险。其中,由人的误操作或不安全行为因素而诱发的电气方面的突发事件已成为医院非医疗事故的主要原因。文章针对医院电气安全操作方面的人因失误,从个人和组织两个角度进行了失误原因的分析,认为人的失误既受个体因素的影响,也受环境、制度和管理水平的影响。在此基础上,提出完善相关规章制度建设、加强教育与培训等,从组织制度建设、人员技术素质提高等方面,提出预防与减少人因失误的措施与方法,提高供配电质量,为医院医疗工作提供有效的电气安全后勤保障。     

A framework for human error risk analysis of coal mine emergency evacuation in China

Evacuation from underground coal mine in emergency as soon as possible makes the difference between life and death. Human factors have an important impact on a successful evacuation, but literature review shows that there is a lack of consideration of human error risk during coal mine emergency evacuation in China. To address the above problems, in this paper, we established a framework for human error risk analysis of coal mine emergency evacuation, consisting of scenario and task analysis, risk assessment and risk reduction. A general evacuation procedure which is applicable for different causes is detailed through the scenario and task analysis. A new method based on expert judgment, named OGI-Model, is proposed to evaluate the reliability of human safety barrier. In this new approach, human safety barrier is divided into three sub-barriers, i.e., organization safety sub-barrier (OSSB), group safety sub-barrier (GSSB), and individual safety sub-barrier (ISSB). Each sub-barrier consists of a series of concrete measures against specific evacuation actions. An example is provided in this paper to demonstrate the use of this framework and its effectiveness.     

Integrating human factors and systems engineering to reduce the risk of operator “error”

Introducing safety devices does not always reduce the frequency of accidents. Operators adjust their response to technological improvements. Protection mechanisms may be used to support “unsafe” working practices so that the net risk of failure remains unchanged or may even rise. Regulatory bodies have reacted against this risk compensation. Rules and procedures have been imposed upon the day-to-day operation of protection equipment. Unfortunately, these constraints often fail to preserve the safety of an application. Inattention, fatigue, poor training and willful neglect can lead to rules and guidelines being ignored. In this paper alternative means of reducing threats posed by risk compensation are explored. In particular, it is argued that designers must exploit an integrated approach to the development of high-risk applications. By this we mean that both human factors and systems engineering must be recruited to support the development of protection equipment.     

A human factors and reliability approach to clinical risk management: Evidence from Italian cases

Similarly to the industrial sector in the late 1980s, nowadays leading organizations in the healthcare sector acknowledge the fact that human errors, adverse events and system failures must be managed and controlled. Whilst Human Reliability Analysis (HRA) has been well-accepted and integrated into safety management processes in other industries, the application of such error techniques to the problem of managing the associated risks in healthcare is rare. The main purpose of this research is to analyse clinical risk management (CRM) and patient safety improvement in Italian healthcare organizations, through human factors and human reliability theories. In particular, the specific objectives are to explore the Italian state-of-the-art in CRM, with regard to organizational and managerial issues; to identify and verify the factors influencing the growth and sharing of the safety culture and to understand and describe the possibility of transferring human reliability methodologies and theories to the domain of healthcare.Six case studies belonging to the Italian scenario have been performed, in order to describe the Italian healthcare system and to identify the key influencing factors of CRM policies.Results obtained from within and cross-case analysis give an empirical contribution to the recent introduction of CRM in the Italian context and a theoretical contribution referring to the framework used to analyse CRM in healthcare organizations, and to the indications which emerged on the key factors influencing CRM.     

电梯检验过程中的人因失误分析与管理对策

近年来,我国电梯行业发展迅速,但电梯安全事故频发.导致电梯安全事故的原因中,人为失误占很大比重.因此,研究电梯检验过程中的人因失误及管理对策具有重要意义.应用层次分析法构建了理论模型,对可能的人因失误的关键要素进行提取并按相对重要性进行排序,确定了影响人因失误的重要因素.结合近6年南京市电梯检验人因失误的统计数据,应用灰色关联度理论对操作因子进行关联分析,并由此提出了减少电梯检验过程中人因失误的管理建议.     

On the operator action analysis to reduce operational risk in research reactors

Human errors during operation and the resulting increase in operational risk are major concerns for nuclear reactors, just as they are for all industries. Additionally, human reliability analysis together with probabilistic risk analysis is a key element in reducing operational risk. The purpose of this paper is to analyze human reliability using appropriate methods for the probabilistic representation and calculation of human error to be used alongside probabilistic risk analysis in order to reduce the operational risk of the reactor operation. We present a technique for human error rate prediction and standardized plant analysis risk. Human reliability methods have been utilized to quantify different categories of human errors, which have been applied extensively to nuclear power plants. The Tehran research reactor is selected here as a case study, and after consultation with reactor operators and engineers human errors have been identified and adequate performance shaping factors assigned in order to calculate accurate probabilities of human failure.     

组织管理失误对操作人员行为安全影响分析

为使操作人员行为更安全,对组织管理失误进行分析,归纳为管理控制失误、组 织规程失误、组织安全管理失误、安全监督失误、教育培训不足5个方面,运用结构方 程模型（SEM）分析对操作人员行为安全的影响,使用AMOS软件对模型求解。运用直觉 三角模糊数对模型中指标进行评价并采用TOPSIS法对不安全行为进行排序。研究表明: 管理控制和组织规程对建立安全监督体系有正向作用;管理控制和组织规程对组织安全 管理实施有正向作用;管理控制和组织规程对有教育培训正向作用;建立安全监督体系 、组织安全管理实施和教育培训对操作人员安全行为有正向作用。进行风险排序有利于 企业对关键工种提出改进措施,提高企业效益。     

Human error risk analysis in offshore emergencies

Human factors play an important role in the completion of emergency procedures. Human factors analysis is rooted in the concept that humans make errors, and the frequency and consequences of these errors are related to work environment, work culture, and procedures. This can be accounted for in the design of equipment, structures, processes, and procedures. As stress increases, the likelihood of human error also increases. Offshore installations are among the harshest and most stressful work environments in the world. The consequences of human error in an offshore emergency can be severe.A method has been developed to evaluate the risk of human error during offshore emergency musters. Obtaining empirical data was a difficult process, and often little information could be drawn from it. This was especially an issue in determining the consequences of failure to complete muster steps. Based on consequences from past incidents in the offshore industry and probabilities of human error, the level of risk and its tolerability are determined. Using the ARAMIS (accidental risk assessment methodology for industries) approach to safety barrier analysis, a protocol for choosing and evaluating safety measures to reduce and re-assess the risk was developed. The method is assessed using a case study, the Ocean Odyssey incident, to determine its effectiveness. The results of the methodology agree with the analysis of survivor experiences of the Ocean Odyssey incident.     

基于CREAM和贝叶斯网络的空管人误概率预测方法

针对研究管制人因可靠性时存在的模糊性和片面性问题,采用认知可靠性与失误分析方法（CREAM）中的扩展预测法,计算10项管制通用任务的人误概率;在此基础上,以管制行为形成因子作为根节点构建贝叶斯网络,建立其与情景控制模式的不确定关系模型,对管制员在多任务中的人误概率进行预测。研究结果表明:在由相同评判者给出行为形成因子影响效应的前提下,由CREAM扩展预测法和构建贝叶斯网络的方法预测得到的多数任务的人误概率差异较大,从方法的客观性、合理性和适用性角度分析,贝叶斯网络在研究该问题时更具优势。     

Operator-centred local error management in air traffic control

Introduction: A large number of air traffic control occurrences take place without resulting in loss of separation between aircraft. Unfortunately such occurrences are seldom reported and therefore not used for disclosing system weaknesses, such as inappropriate methods and procedures.The ATCC (Air Traffic Control Centre) Malmoe made a trial with local reporting of “learning occurrences”. The trial was ATCO-(Air Traffic Controller) centred. The study objectives were to evaluate if ATCOs would start to report after a defined training and marketing effort, if they could identify system weaknesses, if concrete actions for safety improvement would be taken as a result of the trial and to what extent expert support was necessary.Method and material: The trial period was eight months. The ATCO report would be made on a simple form, available on site. These reports would then be analysed in groups and the marketing and feedback efforts would be co-ordinated by the local flight safety group.Results: 43 reports were filed and analysed during the trial period. The initial motivational training and marketing was considered adequate. During the group discussions, the ATCOs identified system weaknesses within 40 of the reports. The resulting safety improvement actions included: the ATCC unit becoming more active in contacting the pilots and airline companies, the renaming of some waypoints (due to name similarities), the implementation of safer procedures when relieving ATCOs, the training of ATCOs in cockpit flight management systems, and the initiation of a research project primarily concerned with ATCO mental overload.Expert support was required in the beginning to help ATCOs focus on the system rather than on the individual.     

基于DEMATEL的铁路行车人因事故关键因素实证分析

针对铁路行车人因事故受多因素交互影响的问题,提出了一种基于信息熵和DEMATEL法耦合的铁路行车人因事故关键因素实证分析方法。首先依据铁路行车人因事故认知行为模型,从感知、决策、计划和执行4个过程分析铁路行车人因事故的影响因素;然后综合运用信息熵和DEMATEL法构建关键因素量化识别模型,利用中心度和原因度两个参数分析铁路行车人因事故的关键影响因素;最后,结合2008—2013年铁路行车人因事故数据进行实证分析。结果表明,机车操作人员相关情形记忆失误、情景诊断失误、未严格执行操作规则和采取错误行动是铁路行车人因事故的关键影响因素。     

风险管理研究的方法论

根据风险管理兼具自然科学与社会科学特性,阐述了风险管理研究的方法论基础,提出了风险管理研究的方法系统。在此基础上,建立 了涵盖专业维、技术维、逻辑维、理论维、时间维的风险管理研究多维方法论结构体系。归纳了风险管理常用的研究方法,并按方法的层次进 行归类。根据方法系统和方法论的结构体系总结了风险管理研究的一般程序。研究结果在风险管理研究中对减少乃至避免无意义或重复工作具 有重要的指导作用。     

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.     

Managing error on the open road: The contribution of human error models and methods

Despite the provision of various theoretical models and error management methods, error and error-causing conditions remain omnipresent within road transport. This article presents a review of human error models and selected error management approaches, and their applications in a road transport context. The review indicates that such applications, although extant, are limited, and that, compared to other domains, the impact of the models and methods discussed has been only minimal. Reasons for this are discussed, and potential ways in which the models and methods can contribute to road safety are proposed. In conclusion, it is argued that human error models and management methods, although already well integrated within most safety critical domains, still have much to offer to the enhancement of road safety. Further, it is argued that advances in the area, in terms of theoretical and methodological development and validation, are still to be made, and that applications of the error management methods discussed are required to enable such advances.     

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.