Learning from incidents – A method for assessing the effectiveness of the learning cycle

This paper describes a method for assessing the effectiveness in the steps of the learning cycle: the 1st loop with reporting – analysis – decision – implementation – follow-up, and the 2nd loop on an aggregated basis. For each step, the dimensions considered the most relevant for the learning process (scope, quality, timing and information distribution) and for each dimension the most relevant aspects (e.g. completeness and detail) were defined. A method for a semi-quantitative assessment of the effectiveness of the learning cycle was developed using these dimensions and aspects and scales for rating. The method will give clear indications of areas for improvement when applied. The results of the method can also be used for correlation with other safety parameters, e.g. results from safety audits and safety climate inquiries. The method is intended to be used on a sample of the broad range of incidents normally seen in process industry companies. The method was tested on a two-year incident reporting material from six companies from various types of process industries. It was found that the method and the tools worked very well in practice. The results gave interesting insights into the effectiveness of learning from the incidents.     

What can be learned from incidents in chemistry labs

Students of chemistry should achieve certain safety competencies. Among other things they should be able to learn from undesirable events that happen during their work. In order to facilitate this we decided to analyze, together with our students, the specific causes of a few undesirable events which have happened in our school laboratories. We applied an approach based on root cause analysis and on the classification of four levels of safety assurance. Our examples showed the effectiveness of this approach, leading us at once not only to the identification of errors committed by students, but to those of teachers as well. This enabled us to compile a set of recommendations for the possible prevention of such incidents. Above all, our analysis strongly reinforced the conviction that this approach – learning from actual incidents – is more than just a cause analysis technique. It is a pattern of behavior, a cultural pattern. A technique may be analyzed and taught, but the most effective way to pass on a behavioral pattern is to set an example. The best way to show students how to learn from their own errors is for teachers to demonstrate how they have learned from their own experiences. Work in chemistry labs provides ample opportunities for this.     

A framework for learning from incidents in the workplace

Learning from Incidents (LFI) in the workplace has been gaining increasing importance in the Health, Safety and Environment context. Although organisations adopt a variety of LFI initiatives, it is often unclear what learning approaches are the most appropriate and the most effective for different types of incidents across a range of contexts. The aim of the paper is to surface factors that are important for effective Learning from Incidents (LFI). The paper builds on a conceptual framework for learning from incidents, developed through an earlier study. This conceptual framework was validated through empirical data collected at two multinational corporations in the energy sector. From this data a refined framework for learning from incidents was devised with five factors important for LFI: participants of learning, type of incidents, learning process, type of knowledge and learning context. This framework can be used as an evaluation tool and as a guidance tool to develop holistic, organisational learning approaches.     

The role of risk avoidance and locus of control in workers’ near miss experiences: Implications for improving safety management systems

The process industry has made major advancements and is a leader in near-miss safety management, with several validated models and databases to track close call reports. However, organizational efforts to develop safe work procedures and rules do not guarantee that employees will behaviorally comply with them. Assuming that at some point, every safety management system will need to be examined and realigned to help prevent incidents on the job, it is important to understand how personality traits can impact workers' risk-based decisions. Such work has been done in the mining industry due to its characteristically high risks and the results can be gleaned to help the process industry realign goals and values with their workforce. In the current study, researchers cross-sectionally surveyed 1,334 miners from 20 mine sites across the United States, varying in size and commodity. The survey sought to understand how mineworkers' risk avoidance could impact their near miss incidents on the job – a common precursor to lost-time incidents. Multiple regressions showed that as a miner's level of risk avoidance increased by 1 unit in the 6-point response scale, the probability of experiencing a near miss significantly decreased by 30% when adjusting for relevant control variables. Additionally, a significant interaction between risk avoidance and locus of control suggested that the effect of risk avoidance on near misses is enhanced as a miner's locus of control increases. A one-unit increase in locus of control appends the base effect of risk avoidance on near misses with an additional 8% decrease in the probability. Findings are discussed from a near-miss safety management system perspective in terms of methods to foster both risk avoidance and locus of control in an effort to reduce the probability of near misses and lost time at the organizational level within the process industry and other high-hazard industries.     

Lessons learned for process safety management in China

A number of chemical accidents have occurred in China over the past two decades with significant impact on humans and the environment. It is expected that lessons will have been learned from these accidents that will help industries to reduce the risk that catastrophic chemical accidents occur in future. In fact, to some extent there is evidence that lessons have been learned, to the extent that the Chinese government has substantially strengthened legislation and regulatory standards. Nonetheless, there remains a concern that much more still needs to be done to reduce chemical accidents risks in China. Important progress in this area requires not only government support but a commitment across all hazardous industries to learn from past accidents that may in many cases require establishment or considerable improvement of their safety management systems. To assist small and medium-sized enterprises (SMEs), in this effort, results of an analysis of common causes of the chemical accidents reported in the Major Accident Information (MAI) website of Chinese State Administration of Work Safety (SAWS) are presented in this paper In particular, inadequate process hazard analysis (PHA), training and emergency response planning (ERP) were identified as the top three process safety management (PSM) elements that contribute to most of the SMEs accidents in China. Seven recommendations are proposed in order to improve the effectiveness of lesson learning for government agencies and SMEs.     

A summary and synthesis of procedural regulations and standards—Informing a procedures writer's guide

Well-written procedures are an integral part of any industrial organization for safe operation, managing risks, and continuous improvement. Regulatory bodies around the world require industries to have current, accurate, and appropriate procedures for most processes. Although the importance of procedures is recognized by all industries in general, significant incidents still occur due to procedural breakdowns. Some of the procedural breakdowns come from obvious problems such as the procedure not being available or the procedure being wrong. However, some incidents have occurred when correct procedures were available and the operator used those procedures. In these instances, the reason workers do not follow procedures correctly may be attributable the procedure being presented or designed in a manner that does not sufficiently communicate the information in a manner that is easily and quickly understood. This indicates that procedure writers may need more guidance on how to write and design procedures so they accomplish this. To effectively manage risk, procedures need to be technically correct (and regulatory compliant) and usable. As part of this, the current work is focused on developing a systematic approach to a procedure writer's guide that includes a regulatory compliant component. The work presented here consists of an effort to identify procedure-writing practices necessary to ensure regulatory compliance by summarizing a large sample of regulations and standards from several industries. The regulations and standards were organized to reflect common ideas and the implications in terms of human factors needs for procedure design were identified. This information will be used as part of the development of a writer's guide that accounts for human factors (HF) that includes explanations of HF implications and empirical support for each of the guidelines. The novelty of the method and information presented here is in the idea of leveraging the cumulative information available regarding procedures in regulations and standards. Incorporating this information into a procedure's writers guide in this manner may not only facilitate procedure being regulatory compliant for facilities in different geographies of the world, but could also support their being written with considerations for human performance.     

Examining the asymptote in safety progress: a literature review

Many industries are confronted by plateauing safety performance as measured by the absence of negative events – particularly lower-consequence incidents or injuries. At the same time, these industries are sometimes surprised by large fatal accidents that seem to have no connection with their understanding of the risks they faced; or with how they were measuring safety. This article reviews the safety literature to examine how both these surprises and the asymptote are linked to the very structures and practices organizations have in place to manage safety. The article finds that safety practices associated with compliance, control and quantification could be partly responsible. These can create a sense of invulnerability through safety performance close to zero; organizational resources can get deflected into unproductive or counterproductive initiatives; obsolete practices for keeping human performance within a pre-specified bandwidth are sustained; and accountability relationships can encourage suppression of the ‘bad news’ necessary to learn and improve.     

Study of chemical supply system of high-tech process using inherently safer design strategies in Taiwan

The photoelectric, semiconductor and other high-tech industries are Taiwan's most important economic activities. High-tech plant incidents are caused by hazardous energy, even when that energy is confined to the inside of the process machine. During daily maintenance procedures, overhauling or troubleshooting, engineers entering the interior of the machines are in direct contact with the source of the energy or hazardous substances, which can cause serious injury. The best method for preventing such incidents is to use inherently safer design strategies (ISDs); this approach can fully eliminate the dangers from the sources of hazardous energy at a facility.This study first conducts a lithography process hazard analysis and compiles a statistical analysis of the causes of the fires and losses at high-tech plants in Taiwan since 1996, the aim being to establish the necessary improvement measures by using the Fire Dynamics Simulation (FDS) to solve relevant problems. The researchers also investigate the lithography process machine in order to explore carriage improvement measures, and analyse the fires' causes and reactive materials hazardous properties, from 1996 to 2012. The effective improvement measures are established based on the accident statistics. The study site is a 300 mm wafer fabrication plant located in Hsinchu Science Park, Taiwan.After the completion of the annual maintenance jobs improvement from September 2011 to December 2012, the number of lithography process accidents was reduced from 6 to 1. The accident rate was significantly reduced and there were no staff time losses for a continuous 6882 h. It is confirmed that the plant safety level has been effectively enhanced. The researchers offer safety design recommendations regarding transport process appliances, chemical storage tanks, fume cupboard devices, chemical rooms, pumping equipment, transportation pipelines, valve manual box (VMB) process machines and liquid waste discharge lines. These recommendations can be applied in these industries to enhance the safety level of high-tech plants, facilities or process systems.     

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.     

Focus on mission success: Process safety for the Atychiphobist

Modern process plants are complex engineering systems. While thorough reviews of system safeguards are performed, catastrophic events continue to occur, often unfolding in unforeseen ways. Success in process safety demands safe processes, and understanding rare, high consequence events is central to the traditional process safety approach. This philosophy is common to all high-hazard industries, offering the potential for sharing approaches, experience, and lessons learned. The problem, however, is that people (and organizations and entire industries) who fear failure (atychiphobia) sometimes obsess about failure so much that they miss opportunities to succeed.This paper examines selected risk management practices in the power generation and aerospace industries and how those practices have led to improved performance. Risk informed decision making (RIDM) has had widespread application in the nuclear and aerospace industries, and is undergoing enhancements to become a key framework for risk management. Additionally, rather than focusing on avoidance of loss, there are emerging approaches supporting achievement of success. This approach provides a more direct link of risk to business and operational objectives, but does challenge conventional risk approaches founded in a loss prevention-centric view. The paper reflects upon risk informed decision making and success modeling, and suggests how these methods may be applied in the field of process safety. Specific examples are drawn from the defense in depth approach from the nuclear power industry and mission success concepts developed for NASA.     

基于事件提取和改进MMHC的航空旅客运输事故征候贝叶斯网络建模*

为表征航空旅客运输事故征候演化机理,提出事故征候贝叶斯网络的建模方法。基于事故征候中致因事件、结果事件及分类标准的定义,以7 265起事故征候案例为样本,利用事件提取算法,识别事故征候叙述文本中的致因事件,利用改进的最大最小爬山算法实现网络建模;依据事件提取的测试集验证与结构学习的交叉验证,检验建模算法的准确性与有效性;基于证据敏感性指标,识别关键致因事件。结果表明:航空旅客运输事故征候贝叶斯网络模型包含94个节点和247条有向弧。空降冲突、严重设备故障、机组成员疾病及火灾烟雾是模型中高风险关联的致因事件,在安全监管过程中消除或减弱关键致因事件的发生能有效控制系统风险。     

Guidance to improve the effectiveness of process safety management systems in operating facilities

The Process Safety Management (PSM) systems at the operating facilities in the Oil & Gas and in Chemical manufacturing industries have matured over the years and have become, at most facilities, very robust and sophisticated. These programs are administrated by Process Safety (PS) teams at both the corporate business units and plant levels and have been effective in reducing the number and severity of PS events across the industries over the past 25 years or so. Incidents however are occurring at a regular interval and in recent times several noteworthy PS events have occurred in the United States which have brought into question the effectiveness of the PSM programs at play. These facilities have been applying their PSM programs with the expectation that the number and severity of PS events would decrease over time. The expected result has not been realized, especially in context to those facilities that have undergone the recent incidents. Current paper reviews a few publicly available PS performance reports of Oil & Gas and Chemical manufacturing industries. The authors identified a few factors at play that have led to these PS events based on their experience, literature review, and incident investigation reports. Most of the factors are intertwined with multiple PSM elements and it requires a holistic approach to address them. Each of the factors is described and the path forward is proposed to improve the effectiveness of PSM programs.     

Supporting organizational learning by comparing activities and outcomes of the safety-management system

The approach to support organizational learning from pro-active monitoring (activities observations) and deficiencies revealed (outcomes observations) in process-safety incident investigations is proposed.The approach builds on five main steps: i.) Implementation of the incident-investigation procedure at the company level, ii.) Monitoring of the preventive safety activities using various tools, iii.) Identification of the safety outcomes including root-cause analysis, iv.) Comparison of activities observations with outcomes observations in order to reveal latent deficiencies as well as to proof relationships, v.) New universal indicator method is proposed to enhance organizational learning from both activities and outcomes observations.The approach is demonstrated on the implementation at the anonymous SME company. This involved carrying out activities observations in terms of the SMS internal audit and the ARAMIS and the violation-motivation safety-culture questionnaire surveys. The outcomes observations consisted of the three incidents investigations using ECFA+, 3CA and MORT methods. The approach and the case study enabled demonstration of the relationships between activities observations (preventive indicators) and outcomes observations (root causes/deficiencies indicators) and vice versa. We state that such a comparison adds to the justification of the preventive safety performance indicators. Finally, in order to ease the organizational learning from both activities and outcomes observations, universal management indicators attributes/categories are suggested to be followed and are briefly explained based on a modified REWI approach.     

Three accidents in European dynamite production plants: An attempt to improve the external lessons learning

Three serious accidents occurred in three dynamite manufacturing plants within three European countries during a relatively short time period triggering the question of effective external learning. The article discusses the lessons for the prevention of accidents learned from retrospective comparative analysis. It advocates for a better process for learning lessons. It attempts to show how a two level approach to accident analysis may help to reveal a common deeper learning hidden under diverse routine lessons.     

Cycle helmets and road casualties in the UK

OBJECTIVES: Bicycle helmets have been advocated as a means of reducing injury among cyclists. This assertion, derived from a number of case controlled studies carried out in hospitals, conflicts with results from population level studies. In the Western countries where these case control studies have been performed, it appears that cycling morbidity is dominated by sports and leisure users. The generalizability of studies on helmet effectiveness in relation to utilitarian transport cycling is not clear. This study therefore considers population level data for reported road traffic injuries of cyclists and pedestrians. METHODS: Generalized linear and generalized additive models were used to investigate patterns of pedestrian and cyclist injury in the UK based on the police reported "Stats 19" data. Comparisons have been made with survey data on helmet wearing rates to examine evidence for the effectiveness of cycle helmets on overall reported road casualties. While it must be acknowledged that police casualty reports are prone to under-reporting, particularly of incidents involving lower severity casualties the attractive feature of these data are that by definition they only concern road casualties. RESULTS: There is little evidence in UK from the subset of road collisions recorded by the police corresponding to the overall benefits that have been predicted by the results of a number of published case controlled studies. In particular, no association could be found between differing patterns of helmet wearing rates and casualty rates for adults and children. CONCLUSIONS: There is no evidence that cycle helmets reduce the overall cyclist injury burden at the population level in the UK when data on road casualties is examined. This finding, supported by research elsewhere could simply be due to cycle helmets having little potential to reduce the overall transport-related cycle injury burden. Equally, it could be a manifestation of the "ecological fallacy" where it could be conceived that the existence of various sub-groups of cyclists, with different risk profiles, may need to be accounted for in understanding the difference between predicted and realised casualty patterns.     

基于模糊评判人工神经网络的重大危险源辨识研究

国家已经制定了重大危险源辨识标准,辨识依据是危险物质的数量,主要适用于化工行业.本文对于国家重大危险源辨识标准不适合的行业,结合各行业发生事故的特点和工艺特征,综合利用模糊评判法和人工神经网络,辨识企业内存在的重大危险源.在某化工厂进行了检验,实践证明了方法的科学性和合理性.     

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.     

高危行业同类型同等级事件风险要素评价

为提高高危行业安全管理水平,研究风险要素的评价模型。借鉴作业条件危险性评价LEC法理论意义,针对其主观性和间接性太强的缺憾进行了实质性地改进。同时,通过给出风险源强度评估模型及各风险要素强度评估模型,设计同类型同等级事件风险要素的风险贡献度模型。在此基础上,结合改进后的LEC法,建立同类型同等级事件风险要素的风险值模型,风险警戒标准模型以及风险警戒状态模型。验证结果表明:所建模型对风险要素的评价与实际情况较为吻合。