Dominant underlying factors of work related accidents

Chris Pietersen TNO Safety Solutions Consultants BV

General manager

pietersen@safety-sc.comwww.safety-sc.com

TNO SSC Life Cycle Safety

Technical Safety: • Hazard Identification and SIL Classification according to IEC 61508• Qualitative Risk Evaluation e.g. by using Risk Graphs or- Matrices• Quantitative Risk Analysis as also required by authorities (Location Specific Risk and Group

Risk) Organisational Safety: • Organisational factors associated with Safety• Measuring effectiveness from audits en accident analysis studies• The Tripod beta method for determining the problem area’s in an organization Safety Culture: • Safety Culture Maturity assessment• Behaviour Safety Programs    

Statistics of work related incidents

BP Texas refinery explosion 2005

17 people killed due to overfilling and release from ventstack.

Previous five years: OSHA recordable injury rate: down with 70%; Fatality rate with 75%!

What is the story?

Contradiction?

The five most important underlying factors on company level: >   Eroded work environment: resistance to change, lack of motivation and trust. >    No process safety practice and systematic risk reduction practices. Many reorganization took place: lack of communication en clarity about responsibilities. >    Poor hazard awareness and understanding of process safety.>    Poor performance management, no adequate indications of problem area’s.

 

“Missed Opportunities”

Trevor Kletz: (4/12/2000, Singapore):

We find only a single cause (often last one in chain)

We find only the immediate causesWe list human error in a too general wayWe list causes we can do little aboutWe do not share our lessonsWe forget the lessons

Analysis of work related incidents/ accidents> Near misses and small incidents are rooted in the same problem area’s.

> Perform a thorough analysis for the different types of incidents, severity is not a good measure. RCA or Tripod study.

>‘ Manipulation’ of accident statistics by management will lower safety credibility dramatically

Bow-tie model

PREVENT

BEHAVIOUR

ORGANISATION

ENGINEERING

INCIDENT

HAZARDS

MITIGATECONSEQUENCES

LOD, LOP, Hazard management measureBarrier

Safety Measures or Barriers

>The performance of a Risk Inventory for the specific work activities: JSA and/or TRA. For larger projects, a Safety and Health Plan need to be made.

>The procedure to ensure a safe workplace by means of safe constructions and/or by removing the hazard from the installation (e.g. high voltage, hazardous material under pressure in a pipe).

-  Workpermit: Before the work can start, often a workpermit is necessary to make sure that also the hazards of the rest of the installations are taken into account. -  The use of the relevant Personal Protection Equipment (PPE).

Risk Inventory and Safety and Health PlanDutch: RI&E, V&G plan)

>The main problem is that the seemingly generic nature of the work (‘working at height’) has induced generic risk analysis results (e.g. a TRA for working at height in general). In using these, this barrier is ineffective and in fact counter productive to its purpose: to take specific safety measures for the specific job.

> The reporting often is a ‘copy and paste’ result from previous reports. Added value for safety: zero.

Procedure to make sure that the installation is safe

This concerns to make sure that the electrical power is removed, that the pipes are free of pressure and inert, etc.In a company, normally standard procedures exist for this. The immediate cause of failure of this barrier is trivial: it is just the fact that these procedures are not always completely followed. Or are not complete or not (completely) understood

Preconditions

> Job not seen as risky, seen as a routine job.> Work permit not sufficiently focused on work related risks.> Risk analysis too generic.> Work preparation activities not adequate.> Creating a safe installation to work on: not done by the right (experienced) people. >  Project organisation not clear enough.>  Importance and role of the procedure not well understood or procedure not complete/correct.

Underlying factors (Latent Failures)

> Safety perception and behavior different at different levels in the company (Safety culture problem).

> Practice and procedures: 2 worlds.

> Not enough personnel with required knowledge/ experience.

> Almost continuous company reorganizations, creating blind spots in SHE.

> Project management in the company is not focused enough (in an early enough phase) at work safety.

> System for responsibility and supervision is not clear.

SAFETY BY COMMAND

Ten elements of Safety Culture Maturity®

Visible management commitmentSafety communicationProductivity versus safetyLearning organisationParticipation in safetyHealth & safety resourcesRisk-taking behaviorTrust between management and frontline staffIndustrial relations and job satisfaction Safety training

(SCM method Keil Centre)

Necessary steps in learning from incidents1. Detection of a SHE incident2. Reporting of the incident3. Analysis of the incident4. Establishing of the learning effects5. Implementation of the learning effects6. Checking the effectiveness of the

implementation

Step 4: Establishing learning effects

DRIVERSstandards,

policiesMETHODS

e.g. planning, coordination, control

RESOURCESe.g. time, money, people, materials WORKING

ENVIRONMENTincidents

INTENTIONSManagement

ACTIONSSupervisors

CONSEQUENCESOperational staff

1: Single-loop learning2: Double-loop learning3: Triple-loop learning

1

23

Learning loops

• Single-loop learning affects the way operational goals are achieved:

- Without changing the goals, methods or resources.

- It can be described as doing the same things better. It is

visible in modifications of a task protocol, working

instructions or procedures. • Double-loop learning affects norms and organizational targets:

- It can be described as doing things in a better way. Such

changes are visible as changes in resources and methods

used.• Triple-loop learning affects the drivers (policies and values) of

an organization on a high level.

- It can be described as doing other things.

Conclusions

> Dominant underlying factors for work related accidents in the process industry have been identified from incident analysis studies

> Accident statistics generally are not a good indicator for process safety.

> Perform thorough accident analysis studies for underlying factors for a variaty of types

>Learning lessons from accidents only start with the analysis. See the 6 steps.