Common procedural execution failure modes during abnormal situations

The Abnormal Situation Management^® Consortium¹ funded a study to investigate procedural execution failures during abnormal situations. The study team analyzed 20 publically available and 12 corporate confidential incident reports using the TapRoot^® methodology to identify root causes associated with procedural execution failures. The main finding from this investigation was the majority of the procedural execution failures (57%) across these 32 incident reports were associated with abnormal situations. Specific recommendations include potential information to capture from plant incident to better understand the sources of procedural execution failures and improve use of procedures in abnormal situations.     

Percutaneous Exposure Incidents Among Australian Hospital Staff

We investigated all reported percutaneous exposure incidents (PEI) among staff from a large Australian hospital in the 3-year period, 2001-2003. There were a total of 373 PEI, of which 38.9% were needlestick injuries, 32.7% were cutaneous exposures and 28.4% sharps-related injuries. Nurses were the most commonly affected staff members, accounting for 63.5% of the total, followed by doctors (18.8%) and other staff ( 17.7%). Needlestick injuries were responsible for the majority of nurses’ PEI (44.7%). Sharps injuries constituted the major category for doctors (44.3%). Most needlestick injuries (67.6%) were caused by hollow-bore needles, while the majority of cutaneous exposures involved blood or serum (55.8%). Most sharps injures were caused by unknown devices (35.9%) or suture needles (34.9%). Overall, our investigation suggests that PEI is a considerable burden for health care workers in Australia. Further research is now required to determine the relationships, if any, between workers who suffer PEI and those who do not.     

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.     

Method for evaluating learning from incidents using the idea of “level of learning”

Learning from incidents is considered a very important source for learning and improving safety in the process industries. However, the effectiveness of learning from reported incidents can often be questioned. Therefore, there is a need to be able to evaluate the effectiveness of learning from incidents, and for that purpose we need methods and tools. In this paper, a method is described for evaluating the effectiveness of learning, based on the idea of “level of learning” of the lessons learned. The level of learning is expressed in terms of how broadly the lesson learned is applied geographically, how much organizational learning is involved and how long-lasting the effect of learning is. In the 6-step method, the incidents reported in a typical incident learning system are evaluated both for the actual and the potential level of learning in a semi-quantitative way with different tools. The method was applied in six process industries on a large number of incidents. The method was found to be very useful and to give insights of aspects that influence the learning from incidents.     

Effects of passengers on bus driver celeration behavior and incident prediction

PROBLEM: Driver celeration (speed change) behavior of bus drivers has previously been found to predict their traffic incident involvement, but it has also been ascertained that the level of celeration is influenced by the number of passengers carried as well as other traffic density variables. This means that the individual level of celeration is not as well estimated as could be the case. Another hypothesized influence of the number of passengers is that of differential quality of measurements, where high passenger density circumstances are supposed to yield better estimates of the individual driver component of celeration behavior. METHOD: Comparisons were made between different variants of the celeration as predictor of traffic incidents of bus drivers. The number of bus passengers was held constant, and cases identified by their number of passengers per kilometer during measurement were excluded (in 12 samples of repeated measurements). RESULTS: After holding passengers constant, the correlations between celeration behavior and incident record increased very slightly. Also, the selective prediction of incident record of those drivers who had had many passengers when measured increased the correlations even more. CONCLUSIONS: The influence of traffic density variables like the number of passengers have little direct influence on the predictive power of celeration behavior, despite the impact upon absolute celeration level. Selective prediction on the other hand increased correlations substantially. This unusual effect was probably due to how the individual propensity for high or low celeration driving was affected by the number of stops made and general traffic density; differences between drivers in this respect were probably enhanced by the denser traffic, thus creating a better estimate of the theoretical celeration behavior parameter C. The new concept of selective prediction was discussed in terms of making estimates of the systematic differences in quality of the individual driver data.     

经济发展与环境保护双赢政策初探——从临沂治污事件谈起

新环保法实施以来,环境治理工作取得成效显著。但在一些地区具体环保工作的开展中也出现了一些争议。作为争议焦点事件的临沂治霾工作,引发了地方经济发展与环境保护工作二者关系问题的讨论。实现经济发展与环境保护双赢政策,需要建立环保长效机制,完善法律体系,优化管理机制。更好发挥以环境财税体制和排污权交易为代表的经济杠杆作用,实现污染末端治理与源头治理及产业结构优化调整并举,推进环境微观管理与宏观决策的协调统一,同时做好严格执法与完善立法的最优响应工作。     

Modeling using dynamic variables – An approach for the design of loss prevention programs

Records from The National Safety Council [National Safety Council, 2007. Safety Intervention Evaluation: A Systematic Approach. <http://www.acgih.org/events/ControlBand/Thomas_SafetyIntervention.pdf> (accessed 10.01.07)] have shown that in 2004 alone, on-the-job injuries to workers constituted 35% of total recorded injuries in the United States. This generated an associated cost of about $142.2 billion. Unfortunately, the safety intervention programs enforced at work places to mitigate such losses are driven mainly by intuition and experience of involved safety personnel. This paper details implementing a computer program to furnish safety personnel with an empirical basis for designing loss prevention programs based on historical safety data. The computer tool is driven by a dynamic mathematical model which adapts itself to variations in data patterns and explains the correlation between historical incident rates and corresponding resources committed to interventions. This study empowers the industry with a tool that is capable of forming the core of optimizing valuable human resource allocation in safety program designs.     

Lessons learned from recent incidents: Facility siting, atmospheric venting, and operator information systems

Recent incidents have focused attention on a number of technical and management systems that need to be addressed by industry. A multiple layer of protection approach is essential for the prevention of incidents and/or reduction of consequences. Safety culture and operational discipline are the overall embracing factors that influence the safety performance of a facility. However, as recent events have indicated, there are a number of technical and engineering issues that must also be developed and implemented appropriately. Some of these issues that could lead to incidents with catastrophic consequences include facility siting and atmospheric relief venting. Impact of operator information systems on the prevention of releases of hazardous materials from their containment is also another significant factor that should be given appropriate attention.

This paper describes these three topics based on the findings from recent incidents and historical data. Engineering standards, regulatory requirements, and industry practices are discussed for facility siting, atmospheric relief venting, and operator information systems. Finally, a summary of gaps and needs in technology, standards, and practices is presented.     

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.     

A pilot study of citizens' opinions on the Incident Command System in Taiwan

Local residents may have different views on disaster‐response modes depending on their cultural and socioeconomic background. The purpose of this study was to examine Taiwan residents' opinions on the Incident Command System (ICS). We performed a structured survey through face‐to‐face interviews in mudslide‐affected communities. Quantitative analysis showed that the residents exhibited a clear preference for the ICS core‐principle attributes of ‘integrated communications’, ‘transfer of command’ and ‘modular organisation’. By contrast, the residents tended towards a non‐ICS approach for ‘incident action plan’ and ‘manageable span of control’. Qualitative analysis revealed an uncertain attitude towards ‘transfer of command’ and ‘incident action plan’. Community acceptance is important in the promotion of the ICS. A better understanding of residents' preferences should be acquired through a broader community survey, allowing us to understand perspectives on the ICS among different societies and facilitate implementation of the ICS at the basic community level.