Learning from major accidents to improve system design

© 2015 Elsevier Ltd.Despite the massive developments in new technologies, materials and industrial systems, notably supported by advanced structural and risk control assessments, recent major accidents are challenging the practicality and effectiveness of risk control measures designed to improve reliability and reduce the likelihood of losses. Contemporary investigations of accidents occurred in high-technology systems highlighted the connection between human-related issues and major events, which led to catastrophic consequences. Consequently, the understanding of human behavioural characteristics interlaced with current technology aspects and organisational context seems to be of paramount importance for the safety & reliability field. First, significant drawbacks related to the human performance data collection will be minimised by the development of a novel industrial accidents dataset, the Multi-attribute Technological Accidents Dataset (MATA-D), which groups 238 major accidents from different industrial backgrounds and classifies them under a common framework (the Contextual Control Model used as basis for the Cognitive Reliability and Error Analysis Method). The accidents collection and the detailed interpretation will provide a rich data source, enabling the usage of integrated information to generate input to design improvement schemes. Then, implications to improve robustness of system design and tackle the surrounding factors and tendencies that could lead to the manifestation of human errors will be effectively addressed

Análisis y evaluación de la investigación de accidentes laborales como técnicas preventivas en España

Es por esto que resulta necesario definir criterios que permitan ayudar a los técnicos o analistas a adoptar la metodología más idónea dependiendo del contexto y el alcance del accidente en cuestión. Respecto al análisis de los informes de investigación examinados, se determina que solo 1 de cada 4 informes de investigación de accidentes de trabajo realizados por técnicos pertenecientes a alguna de las modalidades organizativas se realizaron siguiendo los criterios de calidad recomendados por los expertos en la materia. Sin embargo, 3 de cada 4 de las investigaciones oficiales de accidentes de trabajo contemplan la totalidad de dichos criterios básicos de calidad. En base a las conclusiones extraídas, y dado las importantes diferencias observadas, se propone crear un modelo común Europeo de informe de investigación de accidente de trabajo con el objetivo de favorecer el aprendizaje a nivel global, y poder difundir de forma homogeneizada los resultados obtenidos en estas investigaciones. Este modelo debe contemplar todos los criterios de calidad básicos para la correcta realización de las investigaciones de accidentes de trabajo tanto en su estructura formal completa como en sus aspectos particulares.El objetivo de esta Tesis Doctoral es ofrecer una visión acerca del estado de la investigación de accidentes de trabajo en España. Este objetivo se fundamenta en el hecho de que la eficacia preventiva de las investigaciones de accidentes de trabajo realizadas por numerosos y variados agentes: Administración Pública, técnicos de servicios de prevención, responsables directos de una investigación en línea, etc., es susceptible de ser aumentada de manera significativa. Esta tesis se encuadra dentro del ámbito de la seguridad y salud laboral. La investigación de accidentes es una técnica analítica de seguridad laboral que tiene por objetivo el análisis de causas que dan lugar a los mismos. Que estas investigaciones se realicen adecuadamente resulta esencial para obtener información útil que ayude a garantizar la no repetición de dichos accidentes. Por ello, partiendo de los distintos criterios de calidad establecidos por expertos en la materia, se efectúa una revisión de la literatura científica que ha tratado la investigación de accidentes de trabajo con el objeto de identificar, clasificar y describir las principales metodologías empleadas en las mismas. Así mismo, se realiza un análisis de investigaciones de accidentes de trabajo realizados por Técnicos en Prevención de Riesgos Laborales de nivel superior. En primera instancia se analizaron 567 investigaciones realizadas por técnicos integrados en alguna de las modalidades organizativas para el desarrollo de las actividades preventivas, sobre accidentes ocurridos en España entre los años 2009 y 2012. Posteriormente se evaluaron 98 informes oficiales de investigación de accidentes de trabajo emitidos por la Autoridad Laboral de Andalucía en el último trimestre de 2014. De acuerdo al análisis realizado se identifican múltiples metodologías. No obstante, la dificultad estriba en elegir la más adecuada

Contributions to risk management : On the balance between value creation and protection

PhD thesis in Risk management and societal safetyThe overall objective of this thesis is to contribute to new knowledge in risk management. More concretely, the research relates to one of the main tasks of risk management: to obtain an appropriate balance between value creation on the one hand and protection on the other. Risk management is considered to be all activities and measures carried out to manage the risk. The main purpose is to support the balancing of the conflicts inherent in exploring opportunities, creating values and development, on the one hand, and avoiding losses and accidents on the other. Many of the situations we face, however, involve high risk and uncertainty, making it challenging to predict the outcomes of our decisions and to obtain an appropriate balance between different concerns such as risk and socioeconomic profitability. Various strategies can form the basis for supporting risk management and decision-making under uncertainty, using different tools and approaches. To adequately inform the decision-makers about the risks and uncertainties, we need to make sure that the strategy we apply, and the approaches and principles that follow, are appropriate for the decision-making context and capable of capturing the relevant uncertainties. This is not straightforward, and there is a need to continuously develop the approaches we use to support the decision-makers. At the same time, we need to acknowledge the fact that the tools we use are just tools, with strong limitations. The quality of the produced decision support, then, relates to the quality of the background knowledge, on which the analyses and evaluations are based. To obtain good quality background knowledge, however, is not always straightforward. The thesis contributes to this end by exploring approaches, principles and underlying ways of thinking related to how we can obtain the appropriate balance between value creation and protection, and by producing new knowledge to support that balance in a specific domain. The scientific contribution of the thesis consists of seven papers. The content and contribution of the seven papers are summarised in the following. In risk management, different strategies can be applied to support the tasks. The strategy refers to the underlying way of thinking and the principles that follow. Amongst the principles, ALARP is central. According to the ALARP principle, risks should be reduced to a level that is As Low As Reasonably Practicable, meaning that risk-reducing measures should be implemented unless the costs are grossly disproportionate to the obtained benefits. By large, however, observations from the industry and literature indicate that analysts focus on single measures in isolation when using the ALARP principle to support decision-making. This underlying way of thinking might lead to misguided decisions: it does not consider that safety measures do not always give the intended effect, as offset effects can occur, and the weight given to the cautionary principle might be inappropriate, given the decision-making context. Paper I discusses and illustrates the importance of systems thinking when using the ALARP principle to guide decision-making under uncertainty. Systems thinking has a role to play, as it enhances the understanding of the decision-making context. Enhancing the understanding and knowledge of a risk-related problem is essential for risk management. The available knowledge (justified beliefs) forms the foundation on which risks are assessed. Different methods exist on how to evaluate the strength of the knowledge, but there is a gap in the literature with respect to methods useful for the identification of relevant knowledge, and an arbitrary approach does not appear to be optimal. Paper II suggests a framework, using a systems approach, to identify and assess the background knowledge, as a means to reduce the risk of missing relevant knowledge and obtain more complete background knowledge, on which risk can be assessed. If we are unable to capture all the relevant knowledge, such as hidden assumptions, the result is incomplete background knowledge, which hampers risk management and the balance between value creation and protection. The available background knowledge needs to be considered in a risk assessment, to inform the decision-makers on, for example, what assumptions the analysts made and what the risk assessment represents. The uncertainties and knowledge need adequate treatment and reflection, in order to produce informative decision support. Paper III contributes to this end and illustrates how the knowledge dimension can be integrated with a risk-based approach, supporting decisions about permanent plug and abandonment of offshore oil and gas wells. The objective of the original approach is to evaluate leakage risk from offshore wells on the basis of consequences and probability, in order to justify more costeffective solutions than the prescriptive ones. Creating cost-effective solutions, however, does not justify less focus on risk and uncertainties, and Paper III suggests an improved approach, which strengthens the decision support on the leakage risk by highlighting the uncertainties, assesses the risk of deviation from the assumptions and reflects the knowledge base. The adoption of safety measures, such as barriers in an offshore well, is an essential activity of risk management. At the same time, it is well known that safety measures do not always give the intended effect, as new safety measures are sometimes offset by other system components. This is problematic for the balance between value creation and avoiding losses, as any company has limited resources for safety expenditure. This implies a need for proper consideration of economic concerns. However, economic evaluations are usually made with sole reference to expected values, in which no or limited weight is given to the cautionary principle. The use of expected values is rational given the portfolio theory, but, at the same time, expected values should be used with care in risk management, as the uncertainties and cautionary principle need stronger weight than what the frame of expected values supports. Papers IV and V discuss and illustrate why traditional economic tools need stronger weight on the cautionary principle when applied in a risk context. Paper IV discusses foundational issues of the use of socioeconomic profitability as a prerequisite for investments in security measures, while Paper V discusses the application of the return of investments in safety (ROSI) measure in the chemical industry. Without considerations of uncertainty and background knowledge, the economic tools might produce misguided decision support, hampering the balance of different concerns. There is an increasing awareness of the importance of the knowledge dimension in the risk science field, in relation to managing risk. The knowledge dimension is split into general knowledge and specific knowledge. The former covers all knowledge available for related activities, whereas the latter covers specific knowledge of activities. For example, to improve patient safety in the emergency medical services, we need to know what can go wrong and why (i.e. general knowledge), but, at the same time, we need to make sure that necessary measures, such as a training programme, are implemented and functioning as intended in the emergency medical services (i.e. specific knowledge), especially when the risk management is subject to scarce resources. Papers VI and VII contribute to the latter, by producing new knowledge about the frequency of training in non-technical skills in the Norwegian emergency medical services. The studies indicate that training has had a positive effect, as the frequency of training in non-technical skills among the personnel in the helicopter emergency service has increased over recent years, and that there is a potential for learning and knowledge sharing between the two emergency medical services. This new specific knowledge provides input to evaluations and future practices of the training programmes, and to increase the general knowledge, which can assist the prehospital services in obtaining an appropriate balance between value creation and protection

How to Use Litigation Technology to Prepare & Present Your Case at Trial October 27, 2021

Meeting proceedings of a seminar by the same name, held October 27, 2021

Factors associated with the severity of construction accidents: The case of South Australia

While the causes of accidents in the construction industry have been extensively studied, severity remains an understudied area. In order to provide more evidence for the currently limited number of empirical investigations on severity, this study analysed 24,764 construction accidents reported during 2002-11 in South Australia. A conceptual model developed through literature uses personal characteristics such as age, experience, gender and language. It also employs work-related factors such as size of organization, project size and location, mechanism of accident and body location of the injury. These were shown to discriminate why some accidents result in only a minor severity while others are fatal. Factors such as time of accident, day of the week and season were not strongly associated with accident severity. When the factors affecting severity of an accident are well understood, preventive measures could be developed specifically to those factors that are at high risk

Identification of injury risk in building construction – education, experience and type of work

Rad prikazuje istraživanje učestalosti povreda na radu građevinskih radnika sa aspekta obrazovanja, iskustva i stručne obučenosti prilikom realizacije različitih vrsta građevinskih radova. Istraživanje je obuhvatilo 719 povreda bez smrtnih posljedica u oblasti građevinarstva u Republici Srbiji u okviru Autonomne pokrajine Vojvodina. Analiza strukture građevinskih radnika, realizirana na osnovu podataka Zavoda za statistiku Republike Srbije, pokazala je da je većina građevinskih radnika (preko 89 %) završila osnovnu ili srednju školu kao i da 17 % radnika u Vojvodini ima manje od pet godina iskustva u građevinarstvu. Na osnovu analize baze podataka o povredama zaključeno je da najveći broj povređenih radnika ima osnovno ili srednje obrazovanje kao i da radnici s većim iskustvom impliciraju manji broj povreda. Također, zaključeno je da je veći dio povreda nastao uslijed nemara radnika na radu, a manji dio uslijed nesigurnih uvjeta rada.This paper presents an overview of research in the frequency of injuries at work among construction workers, from the aspect of education, experience and professional training in the realization of different types of construction works. The research included 719 injuries without fatal outcome in the field of building construction in the Republic of Serbia, within the Autonomous Province of Vojvodina. The analysis of construction workers structure, realized according to the data provided by Statistical Office of the Republic of Serbia, showed that the great majority of construction workers (over 89 %) have elementary or high school education levels, as well as that 17 % of workers in Vojvodina have less than five years of experience in construction. By analyzing the injury base, a conclusion was drawn that the highest number of injured workers has elementary or high school education level, as well as that longer working experience of workers imply smaller number of injuries. In addition, a conclusion was drawn that the injuries were caused to the largest extent owing to workers’ unsafe act, and less owing to unsafe conditions of work