Prevention of accidents through experience feedback

List of figures xiii List of tables xviii Preface xxi Acknowledgements xxv PART I Introduction 1 1 Introducing the concept of SHE information systems 3 1.1 Model of a SHE information system 4 1.2 Human information-processing analogy 6 1.3 What does research tell us about the effects of SHE information systems? 8 1.4 Developing the model further 9 2 Boundary conditions 11 2.1 Conditions inside the company 11 2.1.1 Size, type of technology and resources 11 2.1.2 The organisational context 12 2.2 The outer context 14 2.2.1 The employer’s responsibilities 14 2.2.2 Regulations on record keeping and on the reporting of injuries and incidents to the authorities 16 2.2.3 Workers’ compensation systems 17 2.2.4 International standards and guidelines 18 2.2.5 Other non-governmental organisations 19 3 Alternative accident-prevention approaches 20 3.1 Barriers against hazards 20 3.2 Administrative system for feedback control 21 3.3 Arenas for organisational learning 22 3.4 Risk homeostasis 24 4 Case study: Reducing emissions to the air from a fertiliser plant 25 PART II Theoretical foundation 29 5 Accident models 31 5.1 On the need for accident models 31 5.2 Causal-sequence models 32 5.3 Process models 36 5.4 Energy model 39 5.5 Logical tree models 43 5.6 Human information-processing models 44 5.7 Moving the perspective to the organisational context 45 5.7.1 SHE management models 45 5.7.2 The SHE culture 51 6 Framework for accident analysis 53 6.1 Characteristics of the accident sequence 53 6.2 Consequences of accidents 58 6.2.1 Types of consequences 58 6.2.2 Consequence measures 59 6.2.3 Economic consequences of accidents 61 6.2.4 Actual versus potential losses 63 6.3 Incident (uncontrolled energy flow) 65 6.4 Deviations 67 6.4.1 Heinrich’s classical man-environment taxonomy 67 6.4.2 Ergonomics and industrial-engineering systems views 69 6.5 Contributing factors and root causes 70 6.5.1 Contributing factors at the functional department and work-system levels 72 6.5.2 Root causes at the general and SHE-management-systems levels 76 6.5.3 Problems in identifying causal factors 77 vi Contents 7 Accident counter-measures 82 7.1 Barriers against losses 82 7.1.1 Prevention of occupational accidents 82 7.1.2 Prevention of major accidents due to fires and explosions 83 7.2 Active and passive barriers 86 7.3 Different time frames in the implementation and maintenance of barriers 86 7.4 The role of experience transfer 87 7.5 Designing for safety of machinery 89 7.6 Safety measures in operation 92 7.6.1 The permit-to-work system 93 8 The human element in accident control 95 8.1 Human information processing 95 8.2 Human errors 100 8.2.1 Definition 100 8.2.2 Human-error taxonomies 101 8.2.3 Error recovery 102 8.2.4 The influence of emotion 104 8.2.5 Preventing human errors and promoting error recovery 105 8.3 The role of the operators in major-accident prevention 107 8.3.1 Unscheduled manual interventions 107 8.3.2 Fallacy of the defences-in-depth philosophy 109 8.3.3 High-reliability organisations 110 9 The occurrence of accidents over time 111 10 Feedback and use of experiences in decision-making 114 10.1 Overview of feedback mechanisms 114 10.2 Uses of SHE-related information in decision-making 115 10.3 The diagnostic process 117 10.3.1 Effects of limitations in human information-processing capacity 119 10.3.2 Hale’s problem-solving cycle 120 10.3.3 Deming’s circle 122 10.4 Persistent feedback control 123 10.5 Ashby’s law of requisite variety 124 10.6 Van Court Hare’s hierarchy of order of feedback 126 Contents vii 10.7 Obstacles to an efficient learning from experience 129 10.7.1 Organisational defences 129 10.7.2 Local information and the SHE information system 130 10.7.3 Culpability and liability 131 10.8 A balanced approach 132 11 Requirements for a SHE information system 134 11.1 Requirements for SHE performance indicators 135 11.2 Requirements for the SHE information system as a whole 136 11.2.1 Data collection 137 11.2.2 Distribution and presentation of information 137 11.2.3 The SHE information system as a whole 139 PART III Learning from incidents and deviations 141 12 Sources of data on accident risks 143 12.1 The ideal scope of different data-collection methods 143 12.2 Filters and barriers in data collection 144 13 Accident and near-accident reporting and investigation 146 13.1 Why report and investigate accidents and near accidents? 146 13.2 Investigations at three levels 147 13.3 Reporting 149 13.3.1 Reporting to the authorities 150 13.3.2 Problems of under-reporting 151 13.3.3 Near-accident reporting 154 13.4 Immediate investigation and follow-up 160 13.4.1 Quality of the supervisor’s first report 160 13.4.2 Use of checklists and reporting forms 161 13.4.3 Displaying the sequence of events 163 13.4.4 Computer-supported accident investigations 167 13.4.5 Registration of accident costs 168 13.5 Group problem-solving 168 13.6 In-depth accident and near-accident investigations 173 13.6.1 The steps in an in-depth investigation 174 13.6.2 Applying SMORT in in-depth investigations 179 13.6.3 Legal aspects of the commission’s report 185 viii Contents 13.7 Computer-supported distribution of the investigation report 186 13.8 A procedure for accident and near-accident reporting and investigation 187 14 SHE inspections and audits 189 14.1 Inspections 189 14.1.1 Workplace inspections 190 14.1.2 Inspecting and testing barrier integrity 193 14.2 SHE audits 194 14.2.1 Application of SMORT in audits 196 15 Accumulated accident experience 198 15.1 Database on accidents and near accidents 199 15.1.1 Database definition 199 15.1.2 Accessing the database 200 15.1.3 Coding of accident and near-accident data 205 15.2 Analysis of accident and near-accident data 209 15.2.1 Finding accident repeaters 209 15.2.2 Uni-and bi-variate distribution analyses 210 15.2.3 Accident-concentration analysis 211 15.2.4 Analysis of accident causes 215 15.2.5 Severity-distribution analysis 216 15.2.6 Extreme-value projection 218 15.3 Experience carriers 221 PART IV Monitoring of SHE performance 225 16 Overview of SHE performance indicators 227 17 Loss-based SHE performance indicators 228 17.1 The lost-time injury frequency rate 228 17.1.1 The control chart 228 17.1.2 The problems of SHE performance measurement 233 17.1.3 Zero-goal mindset 236 17.2 Other loss-based SHE performance indicators 237 17.2.1 Measures of risk 237 17.2.2 Standard loss-based SHE performance indicators 238 17.2.3 Untraditional SHE performance indicators 239 Contents ix 18 Process-based SHE performance indicators 242 18.1 SHE performance indicators based on near-accident reporting 242 18.2 Behavioural sampling 243 19 Causal factor-based SHE performance indicators 248 19.1 Rating the elements of a company’s SHE management system 248 19.1.1 International Safety Rating System (ISRS) 249 19.1.2 Self-rating as a means of improving SHE management 251 19.1.3 Tripod Delta 254 19.2 Measurement of safety climate 255 19.3 Measuring the degree of learning from incidents 256 20 Selecting key SHE performance indicators 258 20.1 Combinations of SHE performance indicators 258 20.2 Indicators of barrier availability 260 PART V Risk analysis 263 21 The risk-analysis process 265 21.1 What is risk analysis? 265 21.2 Acceptance criteria for the risk of losses due to accidents 266 21.3 Methods of risk analysis 267 22 Coarse or energy analysis 271 22.1 Planning 272 22.2 Execution and documentation 273 22.2.1 Identification of hazards and causes 274 22.2.2 Risk estimation 275 22.2.3 Development of safety measures 277 22.2.4 Documentation and follow-up of results 277 22.3 Establishing a database on potential accidents 278 23 Detailed job-safety analysis 280 23.1 Analysis object 280 23.2 Resource needs and scheduling 280 23.3 Description of the steps of the job 281 x Contents 23.4 Subsequent steps 282 23.5 Accidental exposure to chemicals 282 23.6 Systematic mapping of hazards within an organisation 284 24 Risk assessments of machinery 285 24.1 Requirements as to risk assessments 285 24.2 Method for risk assessment 286 24.2.1 Determination of the limits of the machinery (Step 1) 287 24.2.2 Coarse risk assessment (Step 2) 289 24.2.3 Detailed risk assessment of the machinery (Step 3) 293 25 Comparison risk analysis 294 25.1 Acceptance criteria for the risk of occupational accidents 294 25.2 Risk-assessment model 295 25.2.1 Assumptions 296 25.3 The steps of the analysis 297 26 CRIOP 302 PART VI Putting the pieces together 309 27 The oil and gas industry 311 27.1 Accidents in offshore oil and gas production 311 27.2 The Ymer Platform 311 27.2.1 Design 311 27.2.2 Organisation and manning 312 27.3 Prevention of accidents in design 313 27.3.1 The phase model for offshore field exploration and development 313 27.3.2 SHE management principles 316 27.3.3 Prevention of major accidents 322 27.3.4 Prevention of occupational accidents 327 27.4 Construction-site safety 330 27.4.1 SHE management principles 331 27.4.2 Step 1: Pre-qualification 331 27.4.3 Step 2: Tender evaluation and clarification, contract award 332 27.4.4 Step 3: Evaluation of the SHE programmes 333 Contents xi 27.4.5 Step 4: Follow-up during construction 333 27.5 Safety during plant operation 335 27.5.1 SHE management principles 336 27.5.2 Policy and goals 337 27.5.3 Implementation 338 27.5.4 Control and verification 339 28 The trucking industry 344 28.1 Accidents in road transportation 344 28.1.1 Measures of the risk of traffic accidents 345 28.2 The man-vehicle-road-environment model 346 28.2.1 The driver 348 28.2.2 The vehicle 349 28.2.3 The traffic environment 351 28.3 Sources of information on traffic-accident risks 352 28.4 Feedback mechanisms 356 28.4.1 The trucking company 357 28.4.2 The truck manufacturer 359 28.4.3 The roads administration 360 PART VII Improving the corporate SHE information system 363 29 The improvement process 365 29.1 Evaluation of existing conditions 366 29.2 Establishing goals and defining user needs 367 29.3 Developing solutions and following up results 369 30 Design of the system 371 30.1 Database definition 371 30.2 Organisation and routines 372 30.3 Personnel 372 30.4 Instruments and tools 373 31 Epilogue 374 Appendix I: Definitions 376 Appendix II: SMORT questionnaire 379 Bibliography 409 Name index 417 Subject index 419