4,654 research outputs found

    Exploring human error through the safety talk of utilities distribution operatives

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    Cable strikes form a significant safety challenge for the construction industry’s utilities sector. Such incidents can and do result in both death and injury for the workforce, as well as costing companies millions of pounds in associated damages and compensation costs. Despite specialized tools, processes and training programmes, cable strikes still occur on a regular basis. The majority of cable strikes are, like many incidents within the construction industry as a whole, attributed to human error. However, current thinking has suggested that human error is itself a symptom, rather than a cause, and theories have developed to position the incident-causing human error action as the final link in a much longer chain. This paper presents an exploratory study which sought to examine this theory within a specific context; the construction utilities sector and cable strike incidents. Seven interviews were undertaken with operatives within their work environments, which gathered talk around general safety and cable strike incidents. A thematic approach enabled patterns within the transcribed data to be extracted and contextualized within industry practice. Findings indicated that operatives assigned a variety of different causalities to their experiences of incident occurrence, which were then used to construct a taxonomy of the causal factors of cable strikes from the operatives’ perspective. These factors were then analysed within the industry context to construct potential ‘causal chains’ which are able to link the site incidents to management policy. This study, although exploratory, suggests that application of the systems theory of human error is highly applicable to the construction industry, and that the focus of safety management and safety management research should look beyond operatives on the front line to seek further improvements in safety performance

    Imitating Incidents: How Simulation Can Improve Safety Investigation and Learning From Adverse Events

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    Copyright © 2018 Society for Simulation in Healthcare. One of the most fundamental principles of patient safety is to investigate and learn from the past in order to improve the future. However, healthcare organizations can find it challenging to develop the robust organizational processes and work practices that are needed to rigorously investigate and learn from safety incidents. Key challenges include difficulties developing specialist knowledge and expertise, understanding complex incidents, coordinating collaborative action, and positively changing practice. These are the types of challenges that simulation is commonly used to address. As such, this article proposes that there are considerable opportunities to integrate simulation more deeply and systematically into routine efforts to investigate and learn from safety incidents. This article explores how this might be performed by defining five key areas where simulation could be productively integrated throughout the investigation and learning process, drawing on examples of current practice and analogous applications in healthcare and other industries

    A Systems Approach to Assurance of Safety, Security and Sustainability in Railways

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    Human Factors and safety in automated and remote operations in oil and gas: A review

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    This paper explores the Human Factors of automation and remote operations through review of safety literature. The literature was selected through keyword search and snowballing. We have prioritized empirical papers and safety issues based on a systemic perspective. Automation is designed to assist the operators in high and low workload situations. When unexpected events occur and automation fails, it can lead to loss of situational awareness (SA) and reduce system safety. The motivation for remote operations has been to reduce costs and remove operators from hazards. We have not found any systematic literature reviews of safety related to automation or remote operations. Findings indicate that poor design is a root cause in about 50% of the cases. Challenges found in accident investigations are that too many causal factors are categorized as human error. Suggested good practice of user centric design in control facilities are ecological interface design, eye tracking, and design of few and appropriate alarms. There is a lack of communication between system developers and end-users. There is still the challenge of vigilance when monitoring highly automated systems. Automation seems to support safety when it is based on careful design. We see the need for exploration of remote operations and automation in safety critical operations and suggest selecting specific cases together with the industry to document experiences and safety challenges.acceptedVersio

    Report of the workshop on Aviation Safety/Automation Program

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    As part of NASA's responsibility to encourage and facilitate active exchange of information and ideas among members of the aviation community, an Aviation Safety/Automation workshop was organized and sponsored by the Flight Management Division of NASA Langley Research Center. The one-day workshop was held on October 10, 1989, at the Sheraton Beach Inn and Conference Center in Virginia Beach, Virginia. Participants were invited from industry, government, and universities to discuss critical questions and issues concerning the rapid introduction and utilization of advanced computer-based technology into the flight deck and air traffic controller workstation environments. The workshop was attended by approximately 30 discipline experts, automation and human factors researchers, and research and development managers. The goal of the workshop was to address major issues identified by the NASA Aviation Safety/Automation Program. Here, the results of the workshop are documented. The ideas, thoughts, and concepts were developed by the workshop participants. The findings, however, have been synthesized into a final report primarily by the NASA researchers

    Learning from incidents in airworthiness: a novel framework tool for safety analysis

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    peer-reviewedSafe air travel is an expectation that we often invest little or no thought in. Fortunately, the industry has evolved to a stage where major air accidents are rare. Numerous lessons in aviation safety have unfortunately been paid for in the currency of human life. Many segments of the aviation industry support the idea that adverse and unwelcome events can be minimised through diligent reporting of incidents, event analysis and learning. The value of learning from incidents is not well supported in the implementing regulations. Therefore, little or no examination of learning inputs or outputs is required. The intent of the study was to understand how various situations impact on learning from incidents in the continuing airworthiness management segment. To gain an empathetic understanding of the participants and their actions, an interpretative approach was adopted. An analysis of potential research methods and means of data collection was performed. Thirty-four semi-structured taped interviews were carried out. A qualitative analysis process based on Thematic Analysis employing a six- phase approach was used in support of the study. The harvesting of information from incident reporting systems is a necessary input to continuously develop appropriate and effective training material. The inclusion of basic qualification criteria for human factor trainers in regulatory requirements should also be addressed. However, it is questionable if the perpetuation of these measures alone would support more effective delivery and application of lessons learned throughout the segment. One means of addressing this impending issue is to remodel regulatory, operational and training requirements to consider a new approach in the segment. Reflecting a combination of actions, events and conditions in a new basic model for human factor continuation training, may lay the foundations to better elucidate event causation and yield improved safety recommendations in the featured segment

    Comparative Analysis of Nuclear Event Investigation Methods, Tools and Techniques

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    Feedback from operating experience is one of the key means of enhancing nuclear safety and operational risk management. The effectiveness of learning from experience at NPPs could be maximised, if the best event investigation practices available from a series of methodologies, methods and tools in the form of a ‘toolbox’ approach were promoted. Based on available sources of technical, scientific, normative and regulatory information, an inventory, review and brief comparative analysis of information concerning event investigation methods, tools and techniques, either indicated or already used in the nuclear industry (with some examples from other high risk industry areas), was performed in this study. Its results, including the advantages and drawbacks identified from the different instruments, preliminary recommendations and conclusions, are covered in this report. The results of comparative analysis of nuclear event investigation methods, tools and techniques, presented in this interim report, are of a preliminary character. It is assumed that, for the generation of more concrete recommendations concerning the selection of the most effective and appropriate methods and tools for event investigation, new data, from experienced practitioners in the nuclear industry and/or regulatory institutions are needed. It is planned to collect such data, using the questionnaire prepared and performing the survey currently underway. This is the second step in carrying out an inventory of, reviewing, comparing and evaluating the most recent data on developments and systematic approaches in event investigation, used by organisations (mainly utilities) in the EU Member States. Once the data from this survey are collected and analysed, the final recommendations and conclusions will be developed and presented in the final report on this topic. This should help current and prospective investigators to choose the most suitable and efficient event investigation methods and tools for their particular needs.JRC.DDG.F.5-Safety of present nuclear reactor

    Examining the application of STAMP in the analysis of patient safety incidents

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    This thesis examines the application of Systems-Theoretic Accident Model and Processes (STAMP) in healthcare and the analysis of patient safety incidents. Healthcare organisations have a responsibility for the safety of the patients they are treating. This includes the avoidance of unintended or unexpected harm to people during the provision of care. Patient safety incidents, that is adverse events where patients are harmed, are investigated and analysed as accidents are in other safety-critical industries, to gain an understanding of failure and to generate recommendations to prevent similar incidents occurring in the future. However, there is some dissatisfaction with the current quality of incident analysis in healthcare. There is dissatisfaction with the recommendations that are generated from healthcare incident analysis which are felt to produce weak and ineffective remedial actions, often including retraining of individuals and small policy change. Issues with current practice have been linked to the use of Root Cause Analysis (RCA), an analysis method that often results in the understanding of an accident as being the result of a linear chain of events. This type of simple linear approach has been the target of criticism in safety science research and is not felt to be effective in the analysis of incidents in complex systems, such as healthcare. Research in accident analysis methods has developed from a focus on technical failure and individual human actions to consideration of the interactions between people, technology and the organisation. Accident analysis methods have been developed that guide investigations to consideration of the whole system and interactions between system components. These system approaches are judged to be superior to simple linear approaches by the research community, however, they are not currently used in healthcare incident investigation practice. The systems approach of STAMP is felt to be a promising method for the improvement of healthcare incident analysis. STAMP strongly embodies the concepts of systems theory and analyses human decision-making. The application of STAMP in healthcare was investigated through three case studies, which applied STAMP in: 1. The analysis of the large-scale organisational failure at Mid-Staffordshire NHS Trust between 2005-2009. 2. The analysis of a common small-scale hospital-based medication prescription error. 3. The analysis of patient suicide in the community-based services of a Mental Health Trust. The effectiveness of the STAMP applications was evaluated with feedback from healthcare stakeholders on the usability and utility of STAMP and discussion of the STAMP applications against criteria for accident analysis models and methods. Healthcare stakeholders were generally positive about the utility of STAMP, finding it to provide a system view and guide consideration of interactions between system components. They also felt it would help them generate recommendations and were positive about the future application of STAMP in healthcare. However, many felt it to be a complicated method that would need specialist expertise to apply. The STAMP applications demonstrated the ability of STAMP to consider the whole system and guide an analysis to the generation of recommendations for system measures to prevent future incidents. From the findings of the research, recommendations are made to improve STAMP and to assist future applications of STAMP in healthcare. The research also discusses the other factors that influence incident analysis beyond that of the analytical approach used and how these need to be considered to maximise the effectiveness of STAMP
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