Dominant underlying factors of work related accidents Chris Pietersen TNO Safety Solutions Consultants BV General manager pietersen@safety-sc.com www.safety-sc.com

TNO SSC Life Cycle Safety Technical Safety:   Hazard Identification and SIL Classification according to IEC 61508 Qualitative Risk Evaluation e.g. by using Risk Graphs or- Matrices Quantitative Risk Analysis as also required by authorities (Location Specific Risk and Group Risk) Organisational Safety: Organisational factors associated with Safety Measuring effectiveness from audits en accident analysis studies The Tripod beta method for determining the problem area’s in an organization Safety Culture: Safety Culture Maturity assessment Behaviour Safety Programs

Statistics of work related incidents BP Texas refinery explosion 2005 17 people killed due to overfilling and release from ventstack. Previous five years: OSHA recordable injury rate: down with 70%; Fatality rate with 75%! What is the story?

Contradiction? The five most important underlying factors on company level:   ·   Eroded work environment: resistance to change, lack of motivation and trust. ·    No process safety practice and systematic risk reduction practices. Many reorganization took place: lack of communication en clarity about responsibilities. ·    Poor hazard awareness and understanding of process safety. ·    Poor performance management, no adequate indications of problem area’s.

“Missed Opportunities” Trevor Kletz: (4/12/2000, Singapore): We find only a single cause (often last one in chain) We find only the immediate causes We list human error in a too general way We list causes we can do little about We do not share our lessons We forget the lessons

Analysis of work related incidents/ accidents Near misses and small incidents are rooted in the same problem area’s. Perform a thorough analysis for the different types of incidents, severity is not a good measure. RCA or Tripod study. ‘ Manipulation’ of accident statistics by management will lower safety credibility dramatically

Bow-tie model LOD, LOP, Hazard management measure Barrier CONSEQUENCES PREVENT BEHAVIOUR ORGANISATION ENGINEERING INCIDENT HAZARDS MITIGATE CONSEQUENCES

Safety Measures or Barriers The performance of a Risk Inventory for the specific work activities: JSA and/or TRA. For larger projects, a Safety and Health Plan need to be made. The procedure to ensure a safe workplace by means of safe constructions and/or by removing the hazard from the installation (e.g. high voltage, hazardous material under pressure in a pipe). -  Workpermit: Before the work can start, often a workpermit is necessary to make sure that also the hazards of the rest of the installations are taken into account. -  The use of the relevant Personal Protection Equipment (PPE).

Risk Inventory and Safety and Health Plan Dutch: RI&E, V&G plan) The main problem is that the seemingly generic nature of the work (‘working at height’) has induced generic risk analysis results (e.g. a TRA for working at height in general). In using these, this barrier is ineffective and in fact counter productive to its purpose: to take specific safety measures for the specific job. The reporting often is a ‘copy and paste’ result from previous reports. Added value for safety: zero.

Procedure to make sure that the installation is safe This concerns to make sure that the electrical power is removed, that the pipes are free of pressure and inert, etc. In a company, normally standard procedures exist for this. The immediate cause of failure of this barrier is trivial: it is just the fact that these procedures are not always completely followed. Or are not complete or not (completely) understood

Preconditions Job not seen as risky, seen as a routine job. Work permit not sufficiently focused on work related risks. Risk analysis too generic. Work preparation activities not adequate.  Creating a safe installation to work on: not done by the right (experienced) people.   Project organisation not clear enough.   Importance and role of the procedure not well understood or procedure not complete/correct.

Underlying factors (Latent Failures)  Safety perception and behavior different at different levels in the company (Safety culture problem).  Practice and procedures: 2 worlds.  Not enough personnel with required knowledge/ experience.  Almost continuous company reorganizations, creating blind spots in SHE.  Project management in the company is not focused enough (in an early enough phase) at work safety.  System for responsibility and supervision is not clear.

SAFETY BY COMMAND

Ten elements of Safety Culture Maturity® Visible management commitment Safety communication Productivity versus safety Learning organisation Participation in safety Health & safety resources Risk-taking behavior Trust between management and frontline staff Industrial relations and job satisfaction Safety training (SCM method Keil Centre)

Necessary steps in learning from incidents Detection of a SHE incident Reporting of the incident Analysis of the incident Establishing of the learning effects Implementation of the learning effects Checking the effectiveness of the implementation

Step 4: Establishing learning effects INTENTIONS ACTIONS CONSEQUENCES Management Supervisors Operational staff 1 RESOURCES e.g. time, money, DRIVERS people, materials WORKING standards, ENVIRONMENT policies incidents METHODS e.g. planning, coordination, control 3 2 1: Single - loop learning 2: Double - loop learning 3: Triple - loop learning

Learning loops Single-loop learning affects the way operational goals are achieved: Without changing the goals, methods or resources. It can be described as doing the same things better. It is visible in modifications of a task protocol, working instructions or procedures. Double-loop learning affects norms and organizational targets: It can be described as doing things in a better way. Such changes are visible as changes in resources and methods used. Triple-loop learning affects the drivers (policies and values) of an organization on a high level. It can be described as doing other things.

Conclusions Dominant underlying factors for work related accidents in the process industry have been identified from incident analysis studies Accident statistics generally are not a good indicator for process safety. Perform thorough accident analysis studies for underlying factors for a variaty of types Learning lessons from accidents only start with the analysis. See the 6 steps.