The Effectiveness of a “Break Experiment” from a Long-Term Perspective

The study reports the results of a follow-up evaluation, conducted in 1994, of the impact of a training program for female unskilled metal workers that was implemented at the end of the 1970s. The program was designed to promote occupational skills development, and was first evaluated in 1979. On both occasions of evaluation the investment in training was examined from two perspectives, those of the training participants and management. Data were collected through semistructured personal interviews with key members of personnel management and through a group conversation session with a majority of the original course attendees. Supplementary background information was obtained from documents and records maintained by the organization. At some points, there was a convergence of views on the significance of the training program for occupational skills development, at others a divergence. These convergences and divergences are finally discussed and the findings of the study are related to other research on this particular kind of intervention.     

Is biochar or straw-bale construction a better carbon storage from a life cycle perspective?

Biochar has been presented as a key technology for avoiding dangerous climate change. Pyrolysis converts part of the biomass feedstock into a gaseous fraction, which can be used for energy production. The remaining fraction is char, which is highly stable and resistant to biodegradation. When char is added to soil it increases carbon storage, reduces emissions and improves soil quality. Agricultural residues such as straw, stover and hulls are seen as the most accessible raw material. These residues could also be used as insulation in passive energy housing. Straw bale construction is a relatively simple technology, which has been applied for decades. It can store the carbon of the straw material into walls structures and in the process provides energy efficient housing. The climate benefits from improved energy efficiency depend on local conditions and energy production forms. In this study life cycle assessment was used to compare the climate impacts of biochar production and straw bale construction. On a life cycle perspective, straw bale construction results in higher net carbon storage than biochar production (3.3 t CO₂eq vs. 0.9 t CO₂eq/t of straw). However the result was found to be highly dependent on the assumptions on the overall energy efficiency of the replaced building stock.     

Systems thinking in a gas explosion accident – lessons learned from Taiwan

On July 31, 2014, at around 23:57, several huge explosions occurred that lasted for 2 h in Kaohsiung City, Taiwan. As a result of a gas leak from a ruptured underground pipeline, the catastrophic incident destroyed more than 6 km of roads, killed 32 people, injured 321 people, and damaged 3259 buildings. Pipeline explosions have been reported as a repeatedly occurring problem, indicating that (1) complex systems are difficult to manage and control, and (2) humans are unable to effectively learn from experiences of accidents. Initial analyses results reveal that root causes of this incident were a combination of a series of complex chain reactions, which eventually led to propylene leakage and explosion. This is a systematic problem, which can hardly be investigated or analyzed by traditional research approaches. Based on the investigation reports and “systems thinking” method, this study develops causal loop diagrams for the Kaohsiung gas explosion to explore the root causes of the disaster. The research results indicate that (1) this pipeline explosion incident was the result of the chain reactions and was the output of a complex system; (2) the mental model of “production first” and “experience gap” were the root causes of the disaster; and (3) to achieve a higher safety standard, continuous education to improve the mental model of “safety first and safety over production” are essential. The findings of this study may contribute toward the improvement of the standard operating procedure for disaster management and preventing similar incidents in the future.     

What’s past is prologue: Organizational learning from a serious patient injury

This exploratory case study examines how one hospital learned from an adverse event (AE), a medication overdose that seriously injured a patient. Using qualitative data analysis, we examined how four professional groups reacted to the AE: physicians, nurses, pharmacists, and representatives from the combined quality assurance and risk management departments. Following the AE, each professional group classified the event differently, assessed a different segment of history, made decisions about different issues, and chose different courses of action. Despite these differences, the physician, nursing and pharmacy management teams all decided on which solutions to implement before the first root cause analysis meeting was convened. Indeed, to understand how the hospital implemented changes in the aftermath of the AE, it was necessary to examine the learning from near misses and other warnings that preceded it. This case highlights the importance of the politics of organizational learning and raises theoretical and practical questions about how hospitals learn from potential and actual adverse events.     

Insight from hindsight: A practitioner’s perspective on a causal approach to performance improvement

The petrochemical industry works relentlessly on many fronts to improve performance and to create desired performance outcomes. Companies’ approaches vary widely; yet despite best efforts, the industry continues to experience periods of undesirable performance outcomes in product quality, reliability, process safety, environmental, and personal injury. The industry continues to search for better methods, techniques, and technology that are assumed to be missing, but the causes of incidents illustrate that what is in the way of improving performance may not be what is missing but rather what already exists.This paper provides an alternative perspective of performance problems viewed from underlying causes and patterns of causes of incidents in these so-called “high hazard industries” (Carroll, 2004) across several years and geographic regions. The perspective includes two distinct insights.

First, although problems can have a wide range of outcomes and impact, the underlying causal patterns are relatively few in number. These few represent essential elements that are repeatedly discovered in various forms under many unrelated problems.

Second, several common obstacles within organizations often inhibit the ability to find the causes, learn from the causes and to effectively address the causes of performance problems.

The conclusion is that when these repeating patterns are combined with a limited ability to effectively find, learn, and eliminate the causes, organizations are left with repeating periods of performance problems despite well-intended efforts to improve.     

Driving context influences drivers' decision to engage in visual–manual phone tasks: Evidence from a naturalistic driving study

IntroductionVisual–manual (VM) phone tasks (i.e., texting, dialing, reading) are associated with an increased crash/near-crash risk. This study investigated how the driving context influences drivers' decisions to engage in VM phone tasks in naturalistic driving.MethodVideo-recordings of 1,432 car trips were viewed to identify VM phone tasks and passenger presence. Video, vehicle signals, and map data were used to classify driving context (i.e., curvature, other vehicles) before and during the VM phone tasks (N = 374). Vehicle signals (i.e., speed, yaw rate, forward radar) were available for all driving.ResultsVM phone tasks were more likely to be initiated while standing still, and less likely while driving at high speeds, or when a passenger was present. Lead vehicle presence did not influence how likely it was that a VM phone task was initiated, but the drivers adjusted their task timing to situations when the lead vehicle was increasing speed, resulting in increasing time headway. The drivers adjusted task timing until after making sharp turns and lane change maneuvers. In contrast to previous driving simulator studies, there was no evidence of drivers reducing speed as a consequence of VM phone task engagement.ConclusionsThe results show that experienced drivers use information about current and upcoming driving context to decide when to engage in VM phone tasks. However, drivers may fail to sufficiently increase safety margins to allow time to respond to possible unpredictable events (e.g., lead vehicle braking).Practical applicationsAdvanced driver assistance systems should facilitate and possibly boost drivers' self-regulating behavior. For instance, they might recognize when appropriate adaptive behavior is missing and advise or alert accordingly. The results from this study could also inspire training programs for novice drivers, or locally classify roads in terms of the risk associated with secondary task engagement while driving.     

Mortality from road traffic accidents in a rapidly urbanizing Chinese city: A 20-year analysis in Shenzhen, 1994–2013

Objective: This study aimed to describe the trends of motorization and mortality rates from road traffic accidents and examine their associations in a rapidly urbanizing city in China, Shenzhen.

Methods: Using data from the Shenzhen Deaths Registry between 1994 and 2013, we calculated the annual mortality rates of road traffic accidents, in addition to the age- and sex-specific mortality rates and their annual percentage changes (APCs) for the period of 2000–2013. We also examined the associations between mortality rate of road traffic accidents and traffic growth with Spearman's rank correlation analysis and a log-linear model derived from Smeed's law.

Results: A total of 20,196 deaths due to road traffic accidents, including 14,391 (71.3%) male deaths and 5,805 (28.7%) female deaths, were recorded in Shenzhen from 1994 to 2013. The annual mortality rates in terms of deaths per population and deaths per vehicle changed in similar patterns, demonstrating an increase since 1994 and peaking in 1997, followed by a steady decrease thereafter. The decrease in mortality was faster in individuals aged 20 year or older compared to those younger than 20 years. The mortality rates in term of deaths per population were positively correlated with the total number of vehicles per kilometer of road but negatively correlated with the motorization rate in term of vehicles per population. The estimated model for deaths due to road traffic accidents in relation to the total population and the number of registered vehicles was ln (deaths/10,000 vehicles) = ?1.902 × ln (vehicles/population) ? 1.961. The coefficient was statistically significant (P < .001) and the coefficient of determination was 0.966, indicating a good model fit.

Conclusions: We described a generally decreasing trend in the mortality rates of road traffic accidents in a rapidly urbanizing Chinese city based observations in the 20-year period from 1994 to 2013. The decreased mortality rate may be explained by the expansion of road network construction, improved road safety regulations and management, as well as more accessible ambulance services in recent years. Nevertheless, road traffic accidents remain a universal problem of great public health concern in the whole population.     

Is a hands-free phone safer than a handheld phone?

Introduction

Although it is becoming more and more accepted that driving while talking on a cell phone can be hazardous, most jurisdictions are making handheld phone use illegal while allowing hands-free phone use.

Methods

The scientific literature exploring the effects of these two types of cell phone use on driving and driving-related performance is reviewed here.

Results

Our review shows that talking on the phone, regardless of phone type, has negative impacts on performance especially in detecting and identifying events. Performance while using a hands-free phone was rarely found to be better than when using a handheld phone. Some studies found that drivers compensate for the deleterious effects of cell phone use when using a handheld phone but neglect to do so when using a hands-free phone.

Impact on Industry

Current research does not support the decision to allow hands-free phone use while driving.     

Scaling of dust explosion violence from laboratory scale to full industrial scale – A challenging case history from the past

The standardized K_St parameter still seems to be widely used as a universal criterion for ranking explosion violence to be expected from various dusts in given industrial situations. However, this may not be a generally valid approach. In the case of dust explosion venting, the maximum pressure P_max generated in a given vented industrial enclosure is not only influenced by inherent dust parameters (dust chemistry including moisture, and sizes and shapes of individual dust particles). Process-related parameters (degree of dust dispersion, cloud turbulence, and dust concentration) also play key roles. This view seems to be confirmed by some results from a series of large scale vented dust explosion experiments in a 500 m³ silo conducted in Norway by CMI, (now GexCon AS) during 1980–1982. Therefore, these results have been brought forward again in the present paper. The original purpose of the 500 m³ silo experiments was to obtain correlations between P_max in the vented silo and the vent area in the silo top surface, for two different dusts, viz. a wheat grain dust collected in a Norwegian grain import silo facility, and a soya meal used for production of fish farming food. Both dusts were tested in the standard 20-L-sphere in two independent laboratories, and also in the Hartmann bomb in two independent laboratories. P_max and (dP/dt)_max were significantly lower for the soya meal than for the wheat grain dust in all laboratory tests. Because the available amount of wheat grain dust was much larger than the quite limited amount of available soya meal, a complete series of 16 vented silo experiments was first performed with the wheat grain dust, starting with the largest vent area and ending with the smallest one. Then, to avoid unnecessary laborious changes of vent areas, the first experiment with soya dust was performed with the smallest area. The dust cloud in the silo was produced in exactly the same way as with the wheat grain dust. However, contrary to expectations based on the laboratory-scale tests, the soya meal exploded more violently in the large silo than the wheat grain dust, and the silo was blown apart in the very first experiment with this material. The probable reason is that the two dusts responded differently to the dust cloud formation process in the silo on the one hand and in the laboratory-scale apparatuses on the other. This re-confirms that a differentiated philosophy for design of dust explosion vents is indeed needed. Appropriate attention must be paid to the influence of the actual dust cloud generation process on the required vent area. The location and type of the ignition source also play important roles. It may seem that tailored design has to become the future solution for tackling this complex reality, not least for large storage silos. It is the view of the present author that the ongoing development of CFD-based computer codes offers the most promising line of attack. This also applies to design of systems for dust explosion isolation and suppression.     

Moving a hospital: simulation – a way to co-produce safety healthcare facilities

Moving a hospital is a critical period for quality and safety of healthcare. Change is very stressful for professionals. Workers who have experienced relocation of their place of work report deterioration in health status. Building a new hospital or restructuring a unit could provide an opportunity for improving safety and value in healthcare and for ensuring better quality of worklife for the staff. We used in situ simulation to promote experiential learning by training healthcare workers in the workplace in which they are expected to use their skills. In situ simulation was a way to design, plan, assess and implement a new healthcare environment before opening its doors for patient care. We can envisage that simulation will soon be used formally to identify potential problems in healthcare delivery and in staff quality of worklife in new healthcare facilities. Simulation is a way to co-produce a safe and valuable healthcare facility.     

Workers’ exposure to electric fields during the task ‘maintenance of an operating device of circuit breaker from a service platform’ at 110-kV substations

The objective of the study was to investigate occupational exposure to electric fields during the task ‘maintenance of an operating device of circuit breaker from a service platform’ at 110-kV substations. The aim was also to compare the results to Directive 2013/35/EU. At 16 substations, 255 electric field measurements were performed. The highest mean value of the electric fields was 9.6?kV?m^?1. At 63% of substations the maximum values were over 10.0?kV?m^?1, and at 31% of the substations the 75th percentiles were over 10.0?kV?m^?1, which is the low action level (AL) according to Directive 2013/35/EU. All measured values were below the high AL (20.0?kV?m^?1). In the future, it is important to take into account that the measurements were only taken at Finnish 110-kV substations; therefore, it is not possible to generalize these results to other countries and different types of substations.     

Multilevel learning from accidents – Case studies in transport

Substantial efforts have been devoted to accident investigations, but do we gain a reasonable benefit from these efforts? The current study explores multilevel (individual, company, sector/trade, authorities) learning from major accidents and serious incidents. Specifically, this involves identifying a set of learning criteria, i.e. factors or indicators that potentially support and contribute to multilevel learning processes. Identifying such criteria is based on: (i) the accident investigation process, (ii) the follow-up efforts, and (iii) contextual aspects. Three Norwegian accident investigations in transportation (aviation, marine, rail) represent the empirical foundation for the study. Learning criteria were derived by both document analyses from the accidents (e.g. investigation reports) and literature reviews on organizational learning. These were the basis for a workshop regarding learning from accidents, with participants from the aviation, marine, and rail sector. Key results from this workshop are presented and discussed. The study concludes by presenting a set of criteria for learning from accidents.     

Learning from Tabasco’s floods by applying MORT

Natural disasters are increasing alarmingly worldwide in recent years. They have killed millions of people, and adversely affected the life of at least one billion people. Given this, natural disasters present a great challenge to society today concerning how they are to be mitigated so as to produce an acceptable risk is a question which has come to the fore in dramatic ways recently. In 2007, the state of Tabasco, Mexico, was flooded and it is believed that al least one million people were left homeless. The paper addresses the following question: what can be learnt from flood disasters? The paper presents some preliminary results of the analysis of the Tabasco’s flooding by applying the Management Oversight Risk Tree (MORT). The MORT technique may be regarded as a structured checklist in the form of a complex ‘fault-tree’ model that is intended to ensure that all aspects of an organization’s management are looked into when assessing the possible causes of an incident. One of the key conclusions of the present analysis is that the approach to decision making in relation ‘flood management’ at the time of the disaster has not been based explicitly on ‘flood risk assessment’. It is hoped that by conducting such analysis lessons can be learnt so that the impact of natural disasters such as the Tabasco’s flooding can be mitigated in the future.     

Got a risk reduction strategy?

Process safety can be viewed as part of a triad that supports safety in a petrochemical facility. The other two parts are OSHA-type people safety (slips, falls, etc.) and industrial hygiene. The paper will look at process safety from a top down, plant centric view. Process safety can be distilled down to the basic concept of risk reduction. If we reduce risk, our facility will be safer. The obvious problem is that we have potential risks everywhere so how are we going to reduce all these risks to an acceptable level. Clearly we need a strategy or to use a less fancy word – a plan.Too many times it is easy to concentrate on certain aspects such as safety instrumented systems (SIS), layer of protection analysis (LOPA), behavioral safety, prevention, etc. and lose track of the whole picture of what risk reduction entails in a plant.This paper will look at risk reduction in a facility from a plant viewpoint and will cover the details and concepts of risk reduction across a wide spectrum of plant functionalities – safety climate and culture, process safety management, mechanical integrity and risk, layers of protection in risk reduction, loss of containment/hazard relationship, the risk reduction bow-tie diagram, developing a risk reduction strategy, risk reduction strategy elements, and sustainability.It will also discuss some key concepts in dealing with risk reduction in general.     

A drop in the bucket: when is a pay raise a pay raise?

Although merit pay continues to receive much theoretical and practical attention, little systematic effort is devoted to determining how large a pay raise must be before employees see it as a pay raise. This study uses psychophysical reasoning and techniques in a sample of 192 student ‘employees’ to establish the size of pay raise thresholds in a relatively controlled setting. Results indicate that, below about the 7 per cent level, increases in pay amounts are unlikely to evoke positive perceptual and attitudinal reactions among employees. Theoretical, methodological, and practical implications of these results are highlighted. © 1997 by John Wiley & Sons, Ltd.     

Can boreal afforestation help offset incompressible GHG emissions from Canadian industries?

To mitigate greenhouse gas and comply with cap-and-trade systems, the carbon capture and storage (CCS) is presently unviable for industrials dealing with low concentration of CO₂ emissions. Alternatively, a new offset opportunity is being analysed in Canada: the afforestation of open woodlands (OWs) in the boreal territory. The results obtained from model simulations (with CBM-CFS3) showed that afforestation of boreal OWs can be a low C-intensive mitigation activity, in particular when understory planting is the chosen silvicultural approach, so that only 8–12 years are needed to reach a net positive C balance with the afforestation of OWs. A large-scale afforestation of boreal OWs – scheduled at 20 kha per year during 20 years for a maximum of 400 kha – could provide capped industrials with a significant offset potential, for instance up to nearly 8% offset of all Québec industrial process emissions (2009 data) after 45 years. In spite of a certain number of issues that can contribute to the uncertainty of the real environmental and economical benefits from the afforestation of OWs as a mitigation activity – most of which issues are discussed in this paper – this study presented a first glimpse at the extent to which the afforestation of boreal OWs in Québec can provide large emitters with eventually substantial and efficient GHG offset potential, especially those emitters tied up with incompressible GHG emissions.     

The potential for vapour cloud explosions – Lessons from the Buncefield accident

At around 06.00 on Sunday 11th December 2005, a vapour cloud explosion occurred at Buncefield Oil Storage Depot, Hemel Hempstead, Hertfordshire, UK, generating significant blast pressures. However, as a storage site, the Buncefield terminal had very little pipework congestion and at first sight would not have been considered as having much potential for a vapour cloud explosion. As a consequence, one of the actions of the Buncefield Major Incident Investigation Board (BMIIB) was to initiate a review of the possible causes of the severe explosion on the site. This review was then extended to a Joint Industry Project, Phase 1 of which has offered an explanation of the cause of the explosion. The conclusions are summarized along with reference to relevant experimental studies, illustrating how the elements of the explanation were already known. The implications of the incident for the assessment of vapour cloud explosion hazards will be discussed, both in terms of understanding worst case consequences and the use of risk based approaches.     

Using Sound to Reduce Visual Distraction from In-vehicle Human–Machine Interfaces

Objective: Driver distraction and inattention are the main causes of accidents. The fact that devices such as navigation displays and media players are part of the distraction problem has led to the formulation of guidelines advocating various means for minimizing the visual distraction from such interfaces. However, although design guidelines and recommendations are followed, certain interface interactions, such as menu browsing, still require off-road visual attention that increases crash risk. In this article, we investigate whether adding sound to an in-vehicle user interface can provide the support necessary to create a significant reduction in glances toward a visual display when browsing menus.

Methods: Two sound concepts were developed and studied; spearcons (time-compressed speech sounds) and earcons (musical sounds). A simulator study was conducted in which 14 participants between the ages of 36 and 59 took part. Participants performed 6 different interface tasks while driving along a highway route. A 3 × 6 within-group factorial design was employed with sound (no sound /earcons/spearcons) and task (6 different task types) as factors. Eye glances and corresponding measures were recorded using a head-mounted eye tracker. Participants’ self-assessed driving performance was also collected after each task with a 10-point scale ranging from 1 = very bad to 10 = very good. Separate analyses of variance (ANOVAs) were conducted for different eye glance measures and self-rated driving performance.

Results: It was found that the added spearcon sounds significantly reduced total glance time as well as number of glances while retaining task time as compared to the baseline (= no sound) condition (total glance time M = 4.15 for spearcons vs. M = 7.56 for baseline, p =.03). The earcon sounds did not result in such distraction-reducing effects. Furthermore, participants ratings of their driving performance were statistically significantly higher in the spearcon conditions compared to the baseline and earcon conditions (M = 7.08 vs. M = 6.05 and M = 5.99 respectively, p =.035 and p =.002).

Conclusions: The spearcon sounds seem to efficiently reduce visual distraction, whereas the earcon sounds did not reduce distraction measures or increase subjective driving performance. An aspect that must be further investigated is how well spearcons and other types of auditory displays are accepted by drivers in general and how they work in real traffic.