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

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

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

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

境外企业社会安全事件调查分析方法研究

针对我国境外企业在社会安全方面所面临的严峻形势,对境外企业社会安全事件的调查分析方法进行研究.通过对境外中资企业社会安全事件的分类、分级,事件报告和调查的程序,事件统计分析方法等方面的研究,提出境外社会安全事件的分类、分级的标准和原则,境外社会安全事件报告和调查的程序及主要注意事项及统计分析的建议,设计了境外中资企业社会安全事件管理的基本框架,从而加强社会安全事件的调查和统计分析,为科学统计此类事件造成的损失提供依据.     

Migrating an incident reporting system to a CCPS process safety metrics model

A major chemical company established a formal incident investigation and reporting system several years ago. The original system focused heavily on worker-related injuries, illnesses, and near-misses and was used primarily to track statistics reportable to the Occupational Safety and Health Administration (OSHA). This Occupational Injury and Illness (OII) approach has been recognized to be an ineffective tool for measuring, predicting, and preventing process safety incidents. The Center for Chemical Process Safety (CCPS) recently published guidelines on how to establish safety metrics for the measurement and reduction of process safety incidents. The process safety metrics approach relies upon leading and lagging metrics to improve organization process safety. This paper is a case study of the analysis of one organization’s incident database, which represents approximately five years of data from over a dozen facilities. The aim of this investigation was to extract useful process safety metrics from the incident investigation and reporting system, which would be pertinent to the types of process units and process functions at these facilities. This paper will discuss the approach taken to extract process incident information from an OII-based database and present the difficulties of performing an analysis on such a database. This paper provides guidance on how to migrate an existing OII-based reporting system to a program that includes process safety metrics in accordance with industry best practices.     

Harnessing database resources for understanding the profile of chemical process industry incidents

Analyzing historical databases can provide valuable information on the incident occurrences and their consequences for assessing the safety of the chemical process industry. In this study, the RMP and HSEES databases were utilized to understand the patterns and the factors influencing chemical process industry incidents. Frequency exceedance curves were generated by utilizing the different incident consequences from the databases to understand the profile of societal loss from reported incidents. Understanding the statistics and trends of the historical incidents could serve as important lagging indicators in order to assess the probable proximity to major consequences from the low-probability/high-consequence incidents. To this regard, the safety pyramids were also generated to better understand the relationship between the different consequences of the reported incidents. Furthermore, the safety pyramids were analyzed in comparison with the traditional safety pyramid proposed by Heinrich to understand the US process industry incident occurrence trends.     

石油钻井工业事故统计分析

石油钻井工业每年发生大量的事故,造成人员伤亡,环境污染和经济损失。本文通过对中东某采油区13年间3008起各类事故进行统计分析,找出不同因素影响下钻井事故发生的分布规律,为安全管理提供依据。统计结果表明,在炎热的季节,事故发生较为集中,在气候宜人的季节,事故相对较少;斋月所在的月份,事故数量明显增多,与斋月相邻的两个月事故数量明显减少;各类事故按其严重程度呈现金字塔形分布;手脚受伤在LTI中占据相当高的比例;HSE管理质量和承包商的变更对事故的分布有显著的影响。     

Global process safety incidents in the pharmaceutical industry

The objective of this research is to analyse global process safety incidents within the pharmaceutical industry in terms of their consequences and factors contributing to the incidents. There were 73 process safety incidents leading to 108 fatalities found between 1985 and 2019. Trends between the number of incidents, number of fatalities, location, and contributing factors were identified and summarized. The most reported fatalities occurred in 2018 & 2019. 83% of fatalities occurred in China and India. Explosions were associated with 71% of incidents, which resulted in 89% of fatalities. For most of the international incidents, incident investigations were not available and thus insufficient details were available to determine the causes. Contributing factors were available or estimated from available data for about half of the incidents, with the following most common: hazard awareness & identification; operating procedures; design; safeguards, controls & layers of protection; safety culture; and preventive maintenance. These findings can be used as a basis to improve process safety performance in the pharmaceutical industry.     

Do industrial incidents in the chemical sector create equity market contagion?

IntroductionThis paper examines a number of US chemical industry incidents and their effect on equity prices of the incident company. Furthermore, this paper then examines the contagion effect of this incident on direct competitors.MethodEvent study methodology is used to assess the impact of chemical incidents on both incident and competitor companies.ResultsThis paper finds that the incident company experiences deeper negative abnormal returns as the number of injuries and fatalities as a result of the incident increases. The equity value of the competitor companies suffer substantial losses stemming from contagion effects when disasters that occur cause ten or more injuries and fatalities, but benefit from the incident through increasing equity value when the level of injury and fatality is minor.ConclusionsPresence of contagion suggests collective action may reduce value destruction brought about by safety incidents that result in significant injury or loss of life.Practical ApplicationsThis research can be used as a resource to promote and justify the cost of safety mechanisms within the chemical industry, as incidents have been shown to negatively affect the equity value of the not just the incident company, but also their direct competitors.     

Worker-fatigue contributing to workplace incidents in New Zealand Forestry

ProblemReports of incidents in dangerous work environments can be analysed to identify common hazards, in turn aiding in the prevention of future accidents. Whilst studies exist that do this, most focus on causes that involve physical risks. In this paper we propose an alternative approach, and illustrate causes of forestry incidents from the perspective of worker-failure and fatigue. Method This paper outlines the analysis of eight years’ worth of New Zealand forestry incident data, with a focus on the cause of, and time that, incidents occur. Results This has resulted in two main findings. First, 70% of incidents can be attributed, at least in part, to worker-failures. Second, 78% of worker-failure based causes show indications of fatigue. This indicates that a significant number of forestry incidents are caused by worker-fatigue. Finally, this dataset showed inconsistencies in data quality, similar to those that exist in other datasets. This did not affect our analysis. However, these types of errors have the potential to affect the data quality in the national reporting system. Impact on industry The results from this study will be used in a larger project on detecting fatigue in forestry workers for injury and incident prevention. It is also our hope that other researchers may find these results of interest for further fatigue prevention research in hazardous industries.     

The relation of non-culpable traffic incidents to bus drivers' celeration behavior

PROBLEM: The driver celeration behavior theory predicts that celerations are associated with incidents for which the driver has some responsibility in causing, but not other incidents. METHOD: The hypothesis was tested in 25 samples of repeated measurements of bus drivers' celeration behavior against their incidents for two years. RESULTS: The results confirmed the prediction; in 18 samples, the correlation for culpable incidents only was higher than for all incidents, despite the higher means of the latter. Non-culpable incidents had correlations close to zero with celeration. DISCUSSION: It was pointed out that most individual crash prediction studies have not made this differentiation, and thus probably yielded underestimates of the associations sought, although the effect is not strong, due to non-culpable accident involvements being few (less than a third of the total). The methods for correct identification of culpable incident involvements were discussed.     

Risk management of cost consequences in natural gas transmission and distribution infrastructures

A critical aspect of risk management in energy systems is minimizing pipeline incidents that can potentially affect life, property and economic well-being. Risk measures and scenarios are developed in this paper in order to better understand how consequences of pipeline failures are linked to causes and other incident characteristics. An important risk measure for decision-makers in this field is the association between incident cause and cost consequences. Data from the Office of Pipeline Safety (OPS) on natural gas transmission and distribution pipeline incidents are used to analyze the association between various characteristics of the incidents and product loss cost and property damage cost. The data for natural gas transmission incidents are for the period 2002 through May 2009 and include 959 incidents. In the case of natural gas distribution incidents the data include 823 incidents that took place during the period 2004 through May 2009. A two-step approach is used in the statistical analyses to model the consequences and the costs associated with pipeline incidents. In the first step the probability that there is a nonzero consequence associated with an incident is estimated as a function of the characteristics of the incident. In the second step the magnitudes of the consequence measures, given that there is a nonzero outcome, are evaluated as a function of the characteristics of the incidents. It is found that the important characteristics of an incident for risk management can be quite different depending on whether the incident involves a transmission or distribution pipeline, and the type of cost consequence being modeled. The application of this methodology could allow decision-makers in the energy industry to construct scenarios to gain a better understanding of how cost consequence measures vary depending on factors such as incident cause and incident type.     

工业事故调查与分析的发展历程及趋势

工业事故调查伴随着工业革命的发展而开展,而事故分析,特别是系统的分析开展于上世纪的五六十年代。事故调查和分析研究的发展历程可以分成四个阶段,单一原因-结果阶段、多原因-结果阶段、系统化分析阶段以及产业化发展阶段。事故调查和分析从最早的仅仅查找事故（直接）原因单一目的,发展到现在查找（根本）原因、分析原因、制定措施、监督执行等多个目的。事故调查和分析已经发展成为一个学科,一种职业。事故调查和分析的理论和方法也从最初的单方面、表面、短期发展到了全面、深入和系统化。本文在介绍事故调查和分析的发展阶段和过程的同时还将对各阶段代表性的调查方法和理论给予介绍,主要包括＂鱼骨（F ishbone）图＂、＂领结图（BowTie）＂、＂直根（Taproot）图＂和＂三脚架（Tripod）＂。     

A methodology for identifying and addressing dead-legs and corrosion issues in a Process Hazard Analysis (PHA)

Identifying dead-legs and related corrosion issues continues to be a challenge in the process industry. Pipeline corrosion has been a factor in several recent incidents involving releases and fires. A review of incident reports and citations over the past ten years indicates that Process Hazard Analysis (PHA) revalidations have been noted for not addressing the hazards of a process including corrosion mechanisms and dead-legs. In order for the hazards to be addressed, they must first be accurately identified in a PHA and documented along with any recommended actions for preventive maintenance. This paper describes a methodology for identifying and addressing dead-legs and related corrosion issues in a PHA that can be used to update corporate PHA procedures to be more robust in preventing corrosion related incidents.     

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

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

Duty hours and incidents in flight among commercial airline pilots

Introduction. Working long duty hours has often been associated with increased risk of incidents and accidents in transport industries. Despite this, information regarding the intermediate relationship between duty hours and incident risk is limited. This study aimed to test a work hours/incident model to identify the interplay of factors contributing to incidents within the aviation industry. Methods. Nine hundred and fifty-four European-registered commercial airline pilots completed a 30-item survey investigating self-report attitudes and experiences of fatigue. Path analysis was used to test the proposed model. Results. The fit indices indicated this to be a good fit model (χ²?=?11.066, df?=?5, p?=?0.05; Comparative Fit Index?=?0.991; Normed Fit Index?=?0.984; Tucker–Lewis Index?=?0.962; Root Mean Square of Approximation?=?0.036). Highly significant relationships were identified between duty hours and sleep disturbance (r?=?0.18, p?r?=?0.40, p?r?=?0.43, p?Discussion. A critical pathway from duty hours through to self-reported incidents in flight was identified. Further investigation employing both objective and subjective measures of sleep and fatigue is needed.     

Factors associated with occupational injury severity in the New South Wales underground coal mining industry

The relationship between a large number of mine and mine worker characteristics and injury severity was examined using multiple regression techniques. The study was based on data extracted from the New South Wales (N.S.W.) Joint Coal Board's computer based accident/incident reporting system describing 21,372 non-fatal, lost-time injurious incidents that occurred in the N.S.W. underground coal mining industry during the 4 year period from 1 July 1986 to 30 June 1990. The number of days lost as a result of an injurious incident was the best available proxy measure of injury severity. Over the study period, the number of days lost per 100,000 tonnes of raw coal production declined by 73%. Over the same period, injurious incidents involving more than 20 days off work, which constituted only 16% of all injurious incidents in underground mines, resulted in 75% of the total days lost for the whole N.S.W. underground coal mining industry. Factors that had practical importance and that were significantly associated with injury severity included mine worker's age, part of the body injured, type of accident, agency of accident, and mine worker activity. Factors not important or not significant in their relationship with injury severity were: time into shift, previous hours worked, mine location of incident, occupation, work experience, frequency of task, shift, and mining region. This study suggests that factors related to the susceptibility of a mine worker's body tissue to damage or repair, and factors related to the concentration of energy on the mine worker by vehicle and environmental characteristics are important determinants of injury severity.     

Applying systems thinking concepts in the analysis of major incidents and safety culture

In recent years, investigations into major incidents often highlight poor safety culture as one of the key causal factors. These investigations are often assisted by causal analysis tools that help to ensure that the investigation and the information captured are systematic. However, current causal analysis tools are not designed to analyse dynamic complexity of major incidents and safety culture, which arises from the interactions between actors and the temporal and spatial gaps between actions and consequences. This is because most causal analysis tools model events and causal factors linearly. In contrast, systems thinking, a discipline of seeing systems holistically, emphasises the circular nature of complex systems, i.e. cause and effect are not distinguishable. This paper proposes that traditional causal analysis tools and investigation should be enhanced with the use of systems thinking tools.One of the systems thinking tools that is particularly useful in analysing major incidents and safety culture is causal loop diagrams. The diagrams can be used to explain the systemic structure sustaining a safety culture and identify effective interventions to improve the safety culture and prevent a recurrence of a major incident. The paper demonstrates the use of systems thinking and causal loop diagrams through a case study on Bellevue hazardous waste fire in Western Australia. The case study shows how different actors in the system, each acting in reaction to pressures that they are facing, produced and sustained a poor safety culture that was a major contributory factor to the fire in 2001.     

Database for accidents and incidents in the fuel ethanol industry

The purpose of the present research is to collect information about accidents and incidents that have occurred at fuel ethanol facilities from 1998 to October 2014, and to keep complete unified records of them in a database. The developed database contains general information about the accident or incident, its sequence, mitigation measures, its causes and consequences for humans, environment and for the plant. Until now, this information is not available. The work consisted in gathering information from different documental sources and subsequent organization in a database. It complements the previous work made for biodiesel industry and fills the existing gap in the field of ethanol. Knowledge about this information enables us to manage plant risks, since the accidents that are more likely to occur and the main sources of risk can be easily identified. Also, it makes it possible to exchange information with interested third parties. Statistical analysis shows that accident frequency has an oscillatory behavior, rising in the last year. Fire is the most common type of accident, while equipment mechanical failure is the main cause of accident. Partial material loss has been identified as the most common consequence. Finally, some conclusions are obtained concerning to the importance of having an updated and complete accident and incident database.