Prevention of accidents through experience feedback

Title:

Personal Author:

Kjellen, Urban, 1948-

Publication Information:

London : Taylor & Francis, 2000

ISBN:

9780748409259

Subject Term:

Industrial safety

Accidents -- Prevention

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Library	Item Barcode	Call Number	Material Type	Item Category 1	Status
Searching... PSZ JB	30000010063998	T55 K534 2000	Open Access Book	Book	Searching... Unknown

Providing a practical introduction to the basic theories and principals of accident prevention through diagnosis and feedback control, this book presents the various methods and tools of safety, health, and environment (SHE) practice where experience feedback is employed. These include methods of accident and near accident reporting and investigation, workplace inspection, SHE performance measurement, and safety analysis and auditing. It also assesses potentials and limitations of the different methods and tools, including learning from experience of unwanted events and errors. It includes highly applicable data on developing a computer-supported SHE information system.

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

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