“The gift of failure: New approaches to analyzing and learning from events and near-misses.” Honoring the contributions of Bernhard Wilpert

This special issue presents papers from a workshop conducted by New Technologies and Work (NeTWork) to honor the memory of Bernhard Wilpert, the founder and organiser of NeTWork. The papers reflect the theme that undesirable incidents and events, serious and disturbing as they may be, are a “gift of failure.” In short, events offer an opportunity to learn about safe and unsafe operations, generate productive conversations across engaged stakeholders, and bring about beneficial changes to technology, organization, and mental models (understanding). Papers in the special issue are organised around three topics: the process of event analysis, the relationship between event analysis and organisational learning, and learning at multiple system levels. In this introduction we describe the workshop, summarize the contributions of Bernhard Wilpert, suggest three themes that emerged from the workshop, and offer our thoughts about the future of event analysis and learning from events.     

Building Safety indicators: Part 2 – Application,practices and results

Petroleum exploration and production in the Barents Sea is a controversial topic. The Goliat field outside the northern coast of Norway will be the first offshore oil development in this region, with planned production start in 2013–2014. Avoiding major accidents at Goliat is critical; not only to reduce the risks to human lives and the environment, but also to gain political acceptance. Providing early warnings of major accidents for Goliat is one of the main objectives of the research project ‘Building Safety’. The objective of this paper is to describe the development of early warnings in the form of indicators. In addition, the paper includes an overview of current status of early warnings of accidents in other major hazard industries; the nuclear power industry, the chemical process industry, and aviation. Experiences from these industries, including lessons learned from recent major accidents, have been used as important input to the development of early warning indicators.     

The development of probabilistic models to estimate accident risk (due to runway overrun and landing undershoot) applicable to the design and construction of runway safety areas

The risks of landing overrun (LDOR – LanDing OverRun), Take-off Overrun (TOOR – Take-Off OverRun) and landing undershoot (LDUS – LanDing UnderShoot) are dependent on multiple factors related to operating conditions. These include wind, runway surface conditions, landing or take-off distances required, the presence of obstacles, runway distance available, the existence and dimensions of runway safety areas.In this paper we propose risk models for runway overrun and landing undershoot, using a probabilistic approach. These models are supported by historical data on accidents in the area around the runway and will enable us to determine if the risk level is acceptable or whether action must be taken to mitigate such risks at a given airport. Furthermore, these models permit comparison of the results of different risk mitigation actions in terms of operational risk and safety.The principal advantage of this method is the high quality results obtained for a limited investment in terms of time, computing power and data. As such the method is extremely practical and easy to apply in aerodrome planning, development and operation.     

Prediction of the confidence interval for stability analysis of chain pillars in coal mines

The conventional deterministic approach based (DAB) methods are simple and widely used to determine an adequate chain pillar size in coal mines where geological settings, coal characterizations and mining methods have been explored. It is evident that such deterministic methods have some intrinsic limitations in handling uncertainties in material properties, non-regular geometries and different mining operations. In the deterministic stability analysis of a chain pillar, the safety factors as well as all input parameters are deterministic. Although, these parameters generally exhibit uncertainty and should lead to a probabilistic expression for the safety factor. The probabilistic analysis provides a confidence interval to express the reliability of chain pillars stability.In this paper, safety factor is defined as a probabilistic function and the failure probability of designed chain pillar of Tabas coal mine is then evaluated using the First Order Second Moment (FOSM) and the Advanced Second Moment (ASM) methods. The results of the probabilistic stability analysis show that the confidence interval for designed pillars with both mentioned methods applied are similar and their values vary from 84% to 88%. The results of such analyses can be used as a basis for decision-making about the size of chain pillars and reduce the risk of pillars stability as well as the uncertainties. However, a trade-off between cost is essential for making the final decision.     

Organisational learning and continuous improvement of health and safety in certified manufacturers

Certified management systems have increasingly been applied by firms in recent decades and now cover the management of health and safety, principally through the OHSAS 18001 standard. In order to become certified, firms must not only observe the relevant legislation, but also improve performance and raise goals within health and safety on a continuous basis. The article examines how certified occupational and health management systems influence this process to evaluate how far they hinder or support learning. It presents a model with which it is possible to identify and analyse improvement processes. The model is applied to five cases from a qualitative study of Danish manufacturers with certified health and safety management systems. The cases illustrate the wide variation in health and safety management among certified firms.Certification is found to support lower levels of continuous improvement performance in handling health and safety issues. However, more advanced improvement practices are shown to be connected to the integration of health and safety in other managerial areas, as well as to the employment of similar advanced improvement processes within firms. The article argues that certified health and safety management does not obstruct learning, and can support advanced learning. Improvement practices with regard to health and safety are mainly dependent upon the firm’s overall organisational processes and do not automatically arise from the standard alone.     

The development of an intervention to improve the safety of community care nurses while driving and a qualitative investigation of its preliminary effects

This paper details the development of, and perceived role and effectiveness of an innovative intervention designed to ultimately improve the safety of a group of community care (CC) nurses while driving. Recruiting participants from an Australian CC nursing car fleet, qualitative responses from a series of open-ended questions were obtained from drivers (n = 36), supervisors (n = 22), and managers (n = 6). The findings supported the effectiveness of the intervention in reducing self-reported speeding and promoting greater insight into one’s behaviour on the road. This research has important practical implications in that it highlights the value of developing an intervention based on a sound theoretical framework and which is aligned with the needs and beliefs of personnel within a particular organisation.     

Coding ATC incident data using HFACS: Inter-coder consensus

Reliability studies for coding contributing factors of incident reports in high hazard industries are rarely conducted and reported. Although the Human Factors Analysis and Classification System (HFACS) appears to have a larger number of such studies completed than most other systems doubt exists as the accuracy and comparability of results between studies due to aspects of methodology and reporting. This paper reports on a trial conducted on HFACS to determine its reliability in the context of military air traffic control (ATC). Two groups participated in the trial: one group comprised of specialists in the field of human factors and the other group comprised air traffic controllers. All participants were given standardised training via a self-paced workbook and then read 14 incident reports and coded the associated findings. The results show similarly low consensus for both groups of participants. Several reasons for the results are proposed associated with the HFACS model, the context within which incident reporting occurs in real organisations and the conduct of the studies.     

Flammability of hydrocarbon and carbon dioxide mixtures

The effect of carbon dioxide (CO₂) concentration on the ignition behaviour of hydrocarbon and CO₂ gas mixtures is examined in both jets and confined explosions. Results from explosion tests are presented using a 20 l explosion sphere and an 8 m long section of 1.04 m diameter pipeline. Experiments to assess the flame stability and ignition probability in free-jets are reported for a range of different release velocities. An empirically-based flammability factor model for free-jets is also presented and results are compared to ignition probability measurements previously reported in the literature and those resulting from the present tests.The results help to understand how CO₂ changes the severity of fires and explosions resulting from hydrocarbon releases. They also demonstrate that it is possible to ignite gas mixtures when the mean concentration is outside the flammable range. This information may be useful for risk assessments of offshore platforms involved in carbon sequestration or enhanced oil recovery, or in assessing the hazards posed by poorly-inerted hydrocarbon processing plant.     

Trace element concentrations in surface estuarine and marine sediments along the Mississippi Gulf Coast following Hurricane Katrina

Hurricanes are relatively frequent ecological disturbances that may cause potentially long-term impacts to the coastal environment. Hurricane Katrina hit the Mississippi Gulf Coast in August 2005, and caused a storm surge with the potential to change the trace element content of coastal surface sediments. In this study, surface estuarine and marine sediments were collected monthly following the storm from ten sites along the Mississippi Gulf Coast (Mobile Bay, Grand Bay Bayous Heron and Cumbest, Pascagoula, Ocean Springs, Biloxi Gulf, Back Biloxi Bay, Gulfport Gulf, Gulfport Courthouse Rd, and Gulfport Marina). Concentrations of V, Cr, Mn, Fe, Co, Ni, Zn, As, Cd, and Pb were measured by inductively coupled plasma–mass spectrometry to evaluate their temporal and spatial variations in the year following Hurricane Katrina. Sediments were characterized by pH, particle size distribution and total carbon and nitrogen content. Trace element contents of the sediments were determined in both <2 mm and <63 μm grain size fractions. Results revealed no significant temporal and spatial variability in trace element concentrations, in either size fraction. Potential ecological risk of the sediments was assessed by using NOAA SQuiRTs’ guideline values; most concentrations remained below probable adverse effects guidelines to marine organisms suggesting that trace elements redistributed by Hurricane Katrina would not cause an adverse impact on resident organisms. Instead, the concentrations of trace elements were site-dependent, with specific contaminants relating to the use of the area prior to Hurricane Katrina.