1. Dominant underlying factors of work related accidents
Chris Pietersen
TNO Safety Solutions Consultants BV
General manager

2. 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

3. 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?

4. 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.

5. “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

6. 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

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

9. 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).

10. 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.

11. 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

12. 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.

13. 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.

15. SAFETY BY COMMAND

16. 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)

17. 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

18. 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

19. 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.

20. 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.