Table Of ContentPrevention of Accidents and
Unwanted Occurrences
Theory, Methods, and Tools in Safety Management
Prevention of Accidents and
Unwanted Occurrences
Theory, Methods, and Tools in Safety Management
Second Edition
Urban Kjellén
Eirik Albrechtsen
CRC Press
Taylor & Francis Group
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Contents
Preface ................................................................................................................xv
Acknowledgements ....................................................................................xxiii
Authors ............................................................................................................xxv
Section I: Introduction
Chapter 1 Introducing some basic concepts .............................................3
Chapter 2 Framework conditions ................................................................9
2.1 Conditions inside the company .............................................................9
2.1.1 Size, type of technology, and resources .................................9
2.1.2 The organisational context .....................................................11
2.2 Conditions outside the organisation ...................................................13
2.2.1 Regulatory requirements for the management of safety ....13
2.2.2 Regulations on record keeping and on reporting
injuries and incidents to the authorities ...............................15
2.2.3 Workers’ compensation systems ...........................................16
2.2.4 International standards and guidelines ...............................16
2.2.5 Other non-governmental organisations ...............................18
Chapter 3 Case study ..................................................................................19
3.1 Reducing emissions into the air from a fertiliser plant ...................19
Section II: Theoretical foundation
Chapter 4 Accident theory and models ....................................................25
4.1 On the need for accident models .........................................................25
4.2 Causal-sequence models.......................................................................27
4.3 Process models .......................................................................................31
v
vi Contents
4.4 The energy model ..................................................................................34
4.4.1 The Swiss cheese model .........................................................37
4.5 Logical tree models ...............................................................................38
4.6 System models ........................................................................................39
4.6.1 Hierarchical root-cause analysis models .............................40
4.6.2 Safety management models ...................................................40
4.6.3 Systemic accident models .......................................................45
4.7 Use of accident models in investigations of accidents and
near accidents .........................................................................................46
4.8 Safety culture .........................................................................................47
Chapter 5 Framework for accident analysis ............................................51
5.1 Characteristics of the accident sequence ............................................51
5.2 Types of data and scales of measurement ..........................................58
5.3 Consequences of accidents ...................................................................59
5.3.1 Types of consequences ............................................................59
5.3.2 Measures of loss .......................................................................60
5.3.3 Economic consequences of accidents ....................................60
5.3.4 Actual versus potential losses ...............................................66
5.4 Incident (uncontrolled energy flow) ...................................................68
5.5 Deviations ...............................................................................................69
5.6 Contributing factors and root causes ..................................................72
5.6.1 Contributing factors at the functional department
and work-system levels ...........................................................75
5.6.2 Root causes at the general and HSE-management-
systems levels ...........................................................................79
5.6.2.1 Causes derived from quality-assurance
principles ..................................................................80
5.6.3 Causes derived from safety culture elements .....................81
5.6.4 Problems in identifying causal factors .................................81
Chapter 6 The occurrence of accidents over time ..................................87
Chapter 7 Management of safety through experience feedback .......91
7.1 What is meant by experience feedback? .............................................91
7.2 Feedback and use of safety-related information in
decision-making ....................................................................................92
7.3 Feedback mechanisms ..........................................................................94
7.3.1 Juran’s feedback cycle for the control of anything ..............95
7.3.2 The diagnostic process ............................................................96
7.3.3 Deming’s cycle .........................................................................97
7.4 Scope and level of feedback .................................................................98
7.4.1 Ashby’s law of requisite variety ............................................98
7.4.2 Van Court Hare’s hierarchy of order of feedback .............101
Contents vii
7.5 Safety information systems ................................................................104
7.5.1 Developing the model further .............................................107
7.6 Organisational learning......................................................................108
7.7 Obstacles in the management of safety through
experience feedback .............................................................................110
7.7.1 Limitations in human information processing ..................110
7.7.2 Organisational defences .......................................................112
7.8 Effects of experience feedback on the risk of accidents ..................114
Chapter 8 Criteria for assessing the efficiency of
experience feedback ...............................................................117
8.1 The feedback control cycle ..................................................................118
8.1.1 Requirements for safety performance indicators ..............119
8.1.2 Requirements for the different elements of the
safety performance monitoring system and
the system as a whole ............................................................120
8.1.2.1 Data collection .......................................................120
8.1.2.2 Distribution and presentation of information ....122
8.1.2.3 The safety performance monitoring
system as a whole..................................................123
8.2 Diagnosis ..............................................................................................123
8.2.1 Incident investigations ..........................................................123
8.2.1.1 Notification and initial recording .......................124
8.2.1.2 Investigation ..........................................................124
8.2.1.3 Decisions ................................................................125
8.2.1.4 Implementation and follow-up ...........................126
8.2.1.5 Summary ................................................................126
8.2.2 Risk assessment process .......................................................126
Chapter 9 Barriers against loss ................................................................129
9.1 Definitions ............................................................................................130
9.2 Passive and active barriers .................................................................134
9.3 Defence in depth ..................................................................................135
9.4 Limitations of barriers ........................................................................137
9.4.1 Quality of barriers .................................................................140
9.4.2 Inspection, testing and maintenance of barriers ...............141
9.5 Applying barriers in the prevention of
occupational accidents ................................................................142
9.5.1 Machinery safety ...................................................................142
9.5.2 Safety against chemical hazards .........................................146
9.5.3 Safety in the use of cranes ....................................................147
9.5.4 Safety in the use of heavy mobile equipment ...................148
9.6 Permit-to-work system ........................................................................149
9.7 Emergency response management ...................................................152
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Chapter 10 The human element in accident control .............................159
10.1 The human operator as a barrier element ........................................159
10.2 Human error ..........................................................................................162
10.2.1 The theory of risk homeostasis ............................................166
10.2.2 Successful operations and failure-free organisations .......167
10.3 Managing the human element in accident prevention ..................169
10.3.1 Modification of the physical and
organisational context .....................................................170
10.3.2 Personnel-related measures .................................................171
10.3.3 Effectiveness of measures directed at workers .................172
Section III: Learning from incidents and deviations
Chapter 11 Sources of data on accident risks .........................................177
11.1 The ideal scope of different data-collection methods ....................177
11.2 Filters and barriers in data collection ...............................................177
Chapter 12 Hazard identification, safety inspections and audits ......181
12.1 Hazard identification ..........................................................................181
12.2 Safety inspections ................................................................................183
12.2.1 Workplace inspections ..........................................................184
12.2.2 Management inspections .....................................................187
12.2.3 Inspection and testing of barrier integrity ........................188
12.3 Safety audits .........................................................................................189
12.3.1 General guidelines for the auditing of
management systems ............................................................190
12.3.2 Example: Safety audit of a hydropower plant
during refurbishment ...........................................................196
12.3.3 Application of SMORT in audits ..........................................199
Chapter 13 Incident reporting and investigation ..................................201
13.1 Why investigate incidents? .................................................................201
13.2 The steps in the investigation ............................................................202
13.3 Investigations at three levels ..............................................................204
13.3.1 Applying SMORT in investigations at three levels ...........208
13.4 Reporting and first recording of incidents ......................................209
13.4.1 Problems of underreporting .................................................211
13.4.2 The significance of reporting near accidents .....................212
13.4.3 Behaviour theory applied to the reporting of incidents .....215
13.4.4 Employees’ self-reporting of unwanted occurrences .......217
13.4.5 Reporting to the authorities .................................................220
13.5 Immediate (Level 1) investigation and follow-up ...........................221
13.5.1 The quality of the supervisor’s first report ........................221
Contents ix
13.5.2 Well-defined routines for reporting, investigation
and follow-up .........................................................................222
13.5.3 Use of checklists and reporting forms ...............................223
13.6 Internal (Level 2) investigation ..........................................................226
13.6.1 Case: Incident involving flow of water into
tunnel during repair work ...................................................226
13.6.2 Establishing the sequence of events ....................................227
13.6.3 Identification and assessment of deviations ......................233
13.6.4 Barrier analysis ......................................................................233
13.6.5 Analysis of contributing factors in the man–machine
system and at the place of work ..........................................235
13.6.5.1 Group problem-solving ........................................236
13.6.6 Investigating the human factor ...........................................238
13.6.7 Developing accident prevention measures ........................241
13.6.8 Quality assurance of the Level 2 investigation report .....242
13.6.9 Costs of accidents ...................................................................243
13.6.10 Computer-supported investigation, reporting and
follow-up .................................................................................243
13.6.11 Procedure for Level 2 investigations...................................245
13.7 Independent (Level 3) investigation ..................................................245
13.7.1 The steps in an in-depth investigation ...............................248
13.7.1.1 Securing the scene ................................................249
13.7.1.2 Appointing an investigation team......................250
13.7.1.3 Introductory meeting and planning the
team’s work ............................................................251
13.7.1.4 Collection of information.....................................252
13.7.1.5 Evaluation and organising of information ........253
13.7.1.6 Preparing the team’s report .................................254
13.7.1.7 Follow-up meeting ................................................255
13.7.1.8 Follow-up and close-out.......................................255
13.7.2 Applying SMORT in Level 3 investigations.......................255
13.7.2.1 Outline of a SMORT analysis ..............................255
13.7.2.2 Case: Incident involving flow of water
into tunnel during repair work ..........................256
13.7.3 Legal aspects of the team’s report .......................................257
Chapter 14 Accumulated incident experience ........................................261
14.1 Applying incident data in a safety information system ................263
14.2 Incident database .................................................................................264
14.2.1 Coding of incident data ........................................................265
14.3 Accessing the database .......................................................................266
14.4 Analysis of incident data ....................................................................268
14.4.1 Finding incident repeaters ...................................................268
14.4.2 Uni- and bi-variate distribution analyses ..........................269
