A study about changes and their impact on industrial safety

The 15th volume of the Safety Science Monitor, containing the remaining papers from the Workingonsafety.net Conference in Röros, Sep 2010. The Editorial of this issue is the keynote lecture by Raphael D. Huguenin on the theme of the Conference: On the road to vision zero? describing the Swiss application of the Swedish road safety policy. We are grateful to the publisher of Safety Science Monitor, for letting this publication being archived in this Open Access repository. The publication is available at: http://ssmon.chb.kth.se/vol15/issue2/index.phpInternational audienceThe aim of this paper is to introduce a case study aiming at better taking into account the impact of changes on industrial safety. It has been well documented in the past years that many accidents did happen because of changes, combining together technological and social dimensions, making of this issue a complex one. This case study had as a purpose to reduce the complexity of the problem by choosing a technologically and organisationally rather limited system, exploiting hazardous processes, where implications of changes could be identified and discussed with a limited number of persons. Silos, with risk of fires and explosions, are main installations of the seed industry and exploited by a limited number of persons within often medium size organisations. This was therefore a rather good case to start with. After that a company agreed to take part of the research, interviews with individuals and visit of a site was organised. Changes were identified and analysed in relation to industrial safety. Regulatory, organisational and technological changes were retained as significant. The interesting turn of this study occurred when a serious accident happened a few days before the feedback session on the outcomes of the study. The company asked then an investigation to be performed and this provided a very good opportunity to go further in the appreciation of the impact of changes in the light of the accident. The investigation showed that many of the changes identified in the first part of the study did play a strong part in the genesis of the accident, although they were not formulated with the level of details one is able to produce retrospectively with an investigation. This case study brings therefore very interesting empirical data to the question of whether or not one is able to anticipate incidents or accidents given specific technological and organisational configurations and evolutions. This approach of combining both perspectives (a study of changes in normal operation and an accident investigation for the same case) also brings diachronic considerations to the mainly synchronic approach explored so far in studies of normal operations

Safety and security in the light of complexity. Uncertainty & qualification of systems analysis

International audienceThere exists a field of epistemology or philosophy of complexity using contemporary scientific developments for questioning our relationship with reality, knowledge and science developments. This field is extremely stimulating and points at ways of thinking about safety science and risk management in general. This paper will elaborate on and present how the epistemology of complexity - focusing in particular in the challenge of articulating disciplines - offers concepts for tackling accident investigation and auditing of complex sociotechnical systems for at least two purposes worth discussing in light of complexity: safety and security. The discussion will be based on the presentation of Morin's "complex thought", and case studies presented in previous papers which develop these ideas but also from past and current research (since 2000) for the environmental French ministry as well as consulting works for the industry currently carried out by INERIS. This paper will therefore specifically address the issue of modelling (describing, explaining, interpreting, predicting) complex systems for safety and security purposes

Integration of organisational aspects into learning from experience : illustration with a case study

International audienceIn a recent study on learning from experience, INERIS acknowledged the organisational dimensions of major hazard accidents. The aim of this paper is to introduce the approach advocated in order to take into account the organisational aspects of accidents. This approach is based on a review of the literature on the organisational side of major accidents as well as on accident investigation methods. Among the methods, the Accimap (J. Rasmussen, I. Svedung, 2000) was chosen to illustrate the global dimension of accident, and a method (MORT for management oversight and risk tree, Johnson, 1980) has been chosen as a tool to be developed at INERIS, with the collaboration of the Noordwijk Risk Initiative Foundation. This method integrates a normative organisational model and an approach to the accident investigation process, based on the principle of barriers. These two methods, though not completely compatible, have shown to be relevant for serving different objectives of INERIS

Culture sécurité, du débat scientifique a l'expérience de régulation norvégienne

National audienceThis paper steps back and considers the concept of safety culture from a broader perspective. It illustrates the feedback from the Norwegian control authorities of the petrochemical industry (including onshore and offshore installations) in attempting to implement, from a regulatory point of view, safety culture. In a first section, it is shown that culture has many different meanings. Culture can be seen from a philosophical, anthropological, sociological or organisational perspective. Studies of culture and organisations distinguish at least two positions: the functionalist and the interpretive ones. Following the overview offered by this first section, a second section introduces the debates in the literature about safety culture. They broadly replicate the separation established in studies of culture and organisations. It becomes clear, in the light of the two previous sections that the Norwegian experience, which faced difficulties and obstacles, struggled because of the different meanings of the notion of safety culture and of its complexity as an analytical category.Cet article propose une prise de recul sur la notion de culture sécurité et un retour d'expérience sur la mise en oeuvre de ce concept en Norvège, dans le domaine de la pétrochimie (dont les plateformes pétrolières de la mer du Nord), par les autorités publiques. Dans une première partie, il est montré que la culture est un concept polysémique. Ainsi, elle a un sens philosophique mais aussi anthropologique, sociologique ou encore organisationnel. Au sein même des études portant sur les organisations, deux sens sont mis en avant, l'un d'orientation gestionnaire, l'autre à caractère plutôt descriptif. A la lumière de ces uances, les travaux sur la culture sécurité sont présentés. Ils permettent de comprendre pourquoi l'expérience Norvégienne, qui est introduite, s'est heurtée à des obstacles dont les origines se trouvent dans la complexité de la notion et de sa polysémie

A (short) study on the impact of changes on industrial safety

Following incidents and accidents, it appears that, when reading investigations reports, changes always play an important part in the genesis of these events. Yet the problem of change is quite complicated because it includes a wide range of issues, better identified in favour of hindsight. It is indeed much more difficult to predict beforehand those changes that will combine together to lead to a specific unexpected scenario. In order to approach this problem in a way that is manageable and not too ambitious given the complexity of the topic, a short study has been designed to start with, in an industry where installations are simple and number of employees exploiting them limited. Silos were in that respect a good industrial setting for a case study. Silos are exploited by a small amount of people, are relatively simple technologically speaking and decentralised entities within bigger organisational structures, comprising traditional functional departments (maintenance, safety, quality, production). The study consisted in visiting and interviewing within a three days period one site (3 persons) and key people of the organisation (6 persons from various core departments: human resources, safety, maintenance...). The methodology followed for this study was to question all the interviewees about the changes that they could think of in the past, present and in the future in relation with their work, without imposing a specific typology of changes to them. One idea was to represent subsequently a graphic representation (a kind of map) of all changes (past, present and future) according to several categories that would emerge from the interviews. This map would serve as a basis for identifying different potential connections between identified changes, and trying to enhance the ability to locate what might be in the future, based on current trends, consecutive safety problems. This exercise triggers a lot of interesting questions about for instance the frames, schemas or models underlying selections of changes that are seen relevant regarding their impact on safety. Past experience and theorising do play a key role in this process as much as imagination. In this paper, the process and outcomes of this study (including the results of a feedback session to the company planned for the end of February 2010) will be introduced and discussed

Risk analysis method integrating both technical and organisational factors

Safety Management Systems (SMS) are now required in a lot of establishments handling hazardous substances in Europe in application of the council directive 96/82/EC of 9th December 1996 on the control of major-accident hazards involving dangerous substances, known as SEVESO 2 Directive. The Human Factors play obviously an important part in the effectiveness of those safety management systems. Indeed the system depends on the involvement of the people in charge of applying it. Considering the Human Factors from this angle leads the risk analyst to look at the organisation also through its social aspect. The question raised becomes therefore how the relationships, the power plays between workers, the cultural influences can interact with the intended prevention goals of the SMS. The idea would be to allow the risk analyst to foresee the creation mechanisms of the organisational shortcomings at the origin of the major accident. In this paper the author describes the development of a risk analysis approach that creates a focus on the link between the major accident hazards and the activities of the SMS, taking into account the real activities operated for the prevention process. This is a new approach where the individual is not the focus point, like traditionally in the formal Human Error or Human Factor approaches. The individual is considered in the context of the organisation, in its relation with others, in its relation with the processes of the organisation

The regulator-regulatee interaction : insights taken from a risk-laden business firm

The viewpoint taken in this paper is to give a description of the interaction between regulators and regulated organisations, built on an empirical case-study in the French chemical industry

Positionnement et influence du service sécurité dans les industries à risques

National audienceLe contexte économique et social de ces dernières décennies, caractérisé par une forte compétitivité entre les entreprises, un développement rapide des technologies et des pressions des systèmes réglementaires et du public, a entraîné une importante complexification des systèmes sociotechniques. Nos sociétés deviennent ainsi particulièrement vulnérables. Dans ce contexte le risque n’est pas une notion simple à appréhender. L’approche technique, rationnelle (par les normes et les règlementations) reste majoritaire dans les organisations par rapport aux approches par les sciences humaines et sociales. Ces dernières sont cependant essentielles pour capturer la subjectivité de la notion de risque. La thèse présentée ici porte sur le risque industriel dans les installations à risque en fonctionnement quotidien en se basant sur le cadre théorique développé en ergonomie et en sociologie des organisations. Suite à l’identification d’un manque de données empiriques à son sujet malgré sa centralité, l’objet d’étude sera le service sécurité. Son fonctionnement, ses stratégies et son contexte seront analysés à l'aide d'une étude de terrain en vue de comprendre son positionnement et son influence dans l’organisation

Comparison between two organisational models for major hazard prevention

International audienceA clear difficulty today is to find practical organisational modelling dealing specifically with major hazard prevention and to be able to compare them in order to potentially enhance their relevance. This work is an attempt to do so. This paper provides a comparison of the differences, the common and complementary features of the I-RISK model (developed within the European I-RISK project) and the MIRIAM model (developed at INERIS, France)

Aplicación a la iniciativa Reserva Natural Estero Real, Nicaragua: el porqué y el cómo de una línea de base para gobernanza en los ecosistemas costeros

Estas Hojas de Aplicación están diseñadas para operacionalizar el Marco Conceptual y Metodológico de EcoCostas para Manejo de Ecosistemas Costeros, denominado El Porqué y el Cómo de una Línea de Base para Gobernanza. Se trata de una serie completa de ejercicios para preparar una Línea de Base de Gobernanza en una iniciativa de manejo costero. La información desarrollada usando este cuaderno sirve también para alimentar el Sistema de Manejo de Conocimientos de Ecocostas