Prevention of Accidents Through Experience Feedback

451 Pages·2000·9.16 MB·English

by  Urban Kjellen

Prevention of Accidents
Through Experience
Feedback

Prevention of Accidents
Through Experience
Feedback
Urban Kjellén
London and New York
First published 2000 by Taylor & Francis
11 New Fetter Lane, London EC4P 4EE
Simultaneously published in the USA and Canada
by Taylor & Francis
29 West 35th Street, New York NY10001
Taylor & Francis is an imprint of the Taylor & Francis Group
This edition published in the Taylor & Francis e-Library, 2002.
© 2000 Urban Kjellén
All rights reserved. No part of this book may be reprinted or reproduced or
utilised in any form or by any electronic, mechanical, or other means, now
known or hereafter invented, including photocopying and recording, or in any
information storage or retrieval system, without permission in writing from the
publishers.
Every effort has been made to ensure that the advice and information in this
book is true and accurate at the time of going to press. However, neither the
publisher nor the authors can accept any legal responsibility or liability for any
errors or omissions that may be made. In the case of drug administration, any
medical procedure or the use of technical equipment mentioned within this
book, you are strongly advised to consult the manufacturer’s guidelines.
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
Kjellén, Urban, 1948–
Prevention of accidents through experience feedback/Urban Kjellén.
p. cm.
Includes bibliographical references and index.
ISBN 0-7484-0925-4 (hb: alk. paper)
1. Industrial safety. 2. Accidents—Prevention. I. Title.
T55 .K523 2000
363.11¢63–dc21 99–087075
ISBN 0-203-18617-6 Master e-book ISBN
ISBN 0-203-18740-7 (Glassbook Format)
Contents
List of figures xiii
List of tables xviii
Preface xxi
Acknowledgements xxv
PART I
Introduction 1
1 Introducing the concept of SHE information systems 3
1.1 Model of a SHE information system 4
1.2 Human information-processing analogy 6
1.3 What does research tell us about the effects of SHE
information systems? 8
1.4 Developing the model further 9
2 Boundary conditions 11
2.1 Conditions inside the company 11
2.1.1 Size, type of technology and resources 11
2.1.2 The organisational context 12
2.2 The outer context 14
2.2.1 The employer’s responsibilities 14
2.2.2 Regulations on record keeping and on the
reporting of injuries and incidents to the
authorities 16
2.2.3 Workers’ compensation systems 17
2.2.4 International standards and guidelines 18
2.2.5 Other non-governmental organisations 19
vi Contents
3 Alternative accident-prevention approaches 20
3.1 Barriers against hazards 20
3.2 Administrative system for feedback control 21
3.3 Arenas for organisational learning 22
3.4 Risk homeostasis 24
4 Case study: Reducing emissions to the air from a
fertiliser plant 25
PART II
Theoretical foundation 29
5 Accident models 31
5.1 On the need for accident models 31
5.2 Causal-sequence models 32
5.3 Process models 36
5.4 Energy model 39
5.5 Logical tree models 43
5.6 Human information-processing models 44
5.7 Moving the perspective to the organisational context 45
5.7.1 SHE management models 45
5.7.2 The SHE culture 51
6 Framework for accident analysis 53
6.1 Characteristics of the accident sequence 53
6.2 Consequences of accidents 58
6.2.1 Types of consequences 58
6.2.2 Consequence measures 59
6.2.3 Economic consequences of accidents 61
6.2.4 Actual versus potential losses 63
6.3 Incident (uncontrolled energy flow) 65
6.4 Deviations 67
6.4.1 Heinrich’s classical man-environment taxonomy 67
6.4.2 Ergonomics and industrial-engineering systems views 69
6.5 Contributing factors and root causes 70
6.5.1 Contributing factors at the functional department and
work-system levels 72
6.5.2 Root causes at the general and SHE-management-systems
levels 76
6.5.3 Problems in identifying causal factors 77
Contents vii
7 Accident counter-measures 82
7.1 Barriers against losses 82
7.1.1 Prevention of occupational accidents 82
7.1.2 Prevention of major accidents due to fires and
explosions 83
7.2 Active and passive barriers 86
7.3 Different time frames in the implementation and
maintenance of barriers 86
7.4 The role of experience transfer 87
7.5 Designing for safety of machinery 89
7.6 Safety measures in operation 92
7.6.1 The permit-to-work system 93
8 The human element in accident control 95
8.1 Human information processing 95
8.2 Human errors 100
8.2.1 Definition 100
8.2.2 Human-error taxonomies 101
8.2.3 Error recovery 102
8.2.4 The influence of emotion 104
8.2.5 Preventing human errors and promoting
error recovery 105
8.3 The role of the operators in major-accident prevention 107
8.3.1 Unscheduled manual interventions 107
8.3.2 Fallacy of the defences-in-depth philosophy 109
8.3.3 High-reliability organisations 110
9 The occurrence of accidents over time 111
10 Feedback and use of experiences in decision-making 114
10.1 Overview of feedback mechanisms 114
10.2 Uses of SHE-related information in decision-making 115
10.3 The diagnostic process 117
10.3.1 Effects of limitations in human information-processing
capacity 119
10.3.2 Hale’s problem-solving cycle 120
10.3.3 Deming’s circle 122
10.4 Persistent feedback control 123
10.5 Ashby’s law of requisite variety 124
10.6 Van Court Hare’s hierarchy of order of feedback 126
viii Contents
10.7 Obstacles to an efficient learning from experience 129
10.7.1 Organisational defences 129
10.7.2 Local information and the SHE information system 130
10.7.3 Culpability and liability 131
10.8 A balanced approach 132
11 Requirements for a SHE information system 134
11.1 Requirements for SHE performance indicators 135
11.2 Requirements for the SHE information system
as a whole 136
11.2.1 Data collection 137
11.2.2 Distribution and presentation of information 137
11.2.3 The SHE information system as a whole 139
PART III
Learning from incidents and deviations 141
12 Sources of data on accident risks 143
12.1 The ideal scope of different data-collection methods 143
12.2 Filters and barriers in data collection 144
13 Accident and near-accident reporting and investigation 146
13.1 Why report and investigate accidents and
near accidents? 146
13.2 Investigations at three levels 147
13.3 Reporting 149
13.3.1 Reporting to the authorities 150
13.3.2 Problems of under-reporting 151
13.3.3 Near-accident reporting 154
13.4 Immediate investigation and follow-up 160
13.4.1 Quality of the supervisor’s first report 160
13.4.2 Use of checklists and reporting forms 161
13.4.3 Displaying the sequence of events 163
13.4.4 Computer-supported accident investigations 167
13.4.5 Registration of accident costs 168
13.5 Group problem-solving 168
13.6 In-depth accident and near-accident investigations 173
13.6.1 The steps in an in-depth investigation 174
13.6.2 Applying SMORT in in-depth investigations 179
13.6.3 Legal aspects of the commission’s report 185
Contents ix
13.7 Computer-supported distribution of the
investigation report 186
13.8 A procedure for accident and near-accident
reporting and investigation 187
14 SHE inspections and audits 189
14.1 Inspections 189
14.1.1 Workplace inspections 190
14.1.2 Inspecting and testing barrier integrity 193
14.2 SHE audits 194
14.2.1 Application of SMORT in audits 196
15 Accumulated accident experience 198
15.1 Database on accidents and near accidents 199
15.1.1 Database definition 199
15.1.2 Accessing the database 200
15.1.3 Coding of accident and near-accident data 205
15.2 Analysis of accident and near-accident data 209
15.2.1 Finding accident repeaters 209
15.2.2 Uni-and bi-variate distribution analyses 210
15.2.3 Accident-concentration analysis 211
15.2.4 Analysis of accident causes 215
15.2.5 Severity-distribution analysis 216
15.2.6 Extreme-value projection 218
15.3 Experience carriers 221
PART IV
Monitoring of SHE performance 225
16 Overview of SHE performance indicators 227
17 Loss-based SHE performance indicators 228
17.1 The lost-time injury frequency rate 228
17.1.1 The control chart 228
17.1.2 The problems of SHE performance measurement 233
17.1.3 Zero-goal mindset 236
17.2 Other loss-based SHE performance indicators 237
17.2.1 Measures of risk 237
17.2.2 Standard loss-based SHE performance indicators 238
17.2.3 Untraditional SHE performance indicators 239