Dominant underlying factors of work related accidents Chris Pietersen TNO Safety Solutions...
-
Upload
shon-gordon -
Category
Documents
-
view
212 -
download
0
Transcript of Dominant underlying factors of work related accidents Chris Pietersen TNO Safety Solutions...
![Page 1: Dominant underlying factors of work related accidents Chris Pietersen TNO Safety Solutions Consultants BV General manager pietersen@safety-sc.com .](https://reader036.fdocuments.us/reader036/viewer/2022080915/56649de95503460f94ae3f17/html5/thumbnails/1.jpg)
Dominant underlying factors of work related accidents
Chris Pietersen TNO Safety Solutions Consultants BV
General manager
![Page 2: Dominant underlying factors of work related accidents Chris Pietersen TNO Safety Solutions Consultants BV General manager pietersen@safety-sc.com .](https://reader036.fdocuments.us/reader036/viewer/2022080915/56649de95503460f94ae3f17/html5/thumbnails/2.jpg)
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
![Page 3: Dominant underlying factors of work related accidents Chris Pietersen TNO Safety Solutions Consultants BV General manager pietersen@safety-sc.com .](https://reader036.fdocuments.us/reader036/viewer/2022080915/56649de95503460f94ae3f17/html5/thumbnails/3.jpg)
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?
![Page 4: Dominant underlying factors of work related accidents Chris Pietersen TNO Safety Solutions Consultants BV General manager pietersen@safety-sc.com .](https://reader036.fdocuments.us/reader036/viewer/2022080915/56649de95503460f94ae3f17/html5/thumbnails/4.jpg)
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.
![Page 5: Dominant underlying factors of work related accidents Chris Pietersen TNO Safety Solutions Consultants BV General manager pietersen@safety-sc.com .](https://reader036.fdocuments.us/reader036/viewer/2022080915/56649de95503460f94ae3f17/html5/thumbnails/5.jpg)
“Missed Opportunities”
Trevor Kletz: (4/12/2000, Singapore):
We find only a single cause (often last one in chain)
We find only the immediate causesWe list human error in a too general wayWe list causes we can do little aboutWe do not share our lessonsWe forget the lessons
![Page 6: Dominant underlying factors of work related accidents Chris Pietersen TNO Safety Solutions Consultants BV General manager pietersen@safety-sc.com .](https://reader036.fdocuments.us/reader036/viewer/2022080915/56649de95503460f94ae3f17/html5/thumbnails/6.jpg)
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
![Page 7: Dominant underlying factors of work related accidents Chris Pietersen TNO Safety Solutions Consultants BV General manager pietersen@safety-sc.com .](https://reader036.fdocuments.us/reader036/viewer/2022080915/56649de95503460f94ae3f17/html5/thumbnails/7.jpg)
Bow-tie model
PREVENT
BEHAVIOUR
ORGANISATION
ENGINEERING
INCIDENT
HAZARDS
MITIGATECONSEQUENCES
LOD, LOP, Hazard management measureBarrier
![Page 8: Dominant underlying factors of work related accidents Chris Pietersen TNO Safety Solutions Consultants BV General manager pietersen@safety-sc.com .](https://reader036.fdocuments.us/reader036/viewer/2022080915/56649de95503460f94ae3f17/html5/thumbnails/8.jpg)
![Page 9: Dominant underlying factors of work related accidents Chris Pietersen TNO Safety Solutions Consultants BV General manager pietersen@safety-sc.com .](https://reader036.fdocuments.us/reader036/viewer/2022080915/56649de95503460f94ae3f17/html5/thumbnails/9.jpg)
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).
![Page 10: Dominant underlying factors of work related accidents Chris Pietersen TNO Safety Solutions Consultants BV General manager pietersen@safety-sc.com .](https://reader036.fdocuments.us/reader036/viewer/2022080915/56649de95503460f94ae3f17/html5/thumbnails/10.jpg)
Risk Inventory and Safety and Health PlanDutch: 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.
![Page 11: Dominant underlying factors of work related accidents Chris Pietersen TNO Safety Solutions Consultants BV General manager pietersen@safety-sc.com .](https://reader036.fdocuments.us/reader036/viewer/2022080915/56649de95503460f94ae3f17/html5/thumbnails/11.jpg)
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
![Page 12: Dominant underlying factors of work related accidents Chris Pietersen TNO Safety Solutions Consultants BV General manager pietersen@safety-sc.com .](https://reader036.fdocuments.us/reader036/viewer/2022080915/56649de95503460f94ae3f17/html5/thumbnails/12.jpg)
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.
![Page 13: Dominant underlying factors of work related accidents Chris Pietersen TNO Safety Solutions Consultants BV General manager pietersen@safety-sc.com .](https://reader036.fdocuments.us/reader036/viewer/2022080915/56649de95503460f94ae3f17/html5/thumbnails/13.jpg)
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.
![Page 14: Dominant underlying factors of work related accidents Chris Pietersen TNO Safety Solutions Consultants BV General manager pietersen@safety-sc.com .](https://reader036.fdocuments.us/reader036/viewer/2022080915/56649de95503460f94ae3f17/html5/thumbnails/14.jpg)
![Page 15: Dominant underlying factors of work related accidents Chris Pietersen TNO Safety Solutions Consultants BV General manager pietersen@safety-sc.com .](https://reader036.fdocuments.us/reader036/viewer/2022080915/56649de95503460f94ae3f17/html5/thumbnails/15.jpg)
SAFETY BY COMMAND
![Page 16: Dominant underlying factors of work related accidents Chris Pietersen TNO Safety Solutions Consultants BV General manager pietersen@safety-sc.com .](https://reader036.fdocuments.us/reader036/viewer/2022080915/56649de95503460f94ae3f17/html5/thumbnails/16.jpg)
Ten elements of Safety Culture Maturity®
Visible management commitmentSafety communicationProductivity versus safetyLearning organisationParticipation in safetyHealth & safety resourcesRisk-taking behaviorTrust between management and frontline staffIndustrial relations and job satisfaction Safety training
(SCM method Keil Centre)
![Page 17: Dominant underlying factors of work related accidents Chris Pietersen TNO Safety Solutions Consultants BV General manager pietersen@safety-sc.com .](https://reader036.fdocuments.us/reader036/viewer/2022080915/56649de95503460f94ae3f17/html5/thumbnails/17.jpg)
Necessary steps in learning from incidents1. Detection of a SHE incident2. Reporting of the incident3. Analysis of the incident4. Establishing of the learning effects5. Implementation of the learning effects6. Checking the effectiveness of the
implementation
![Page 18: Dominant underlying factors of work related accidents Chris Pietersen TNO Safety Solutions Consultants BV General manager pietersen@safety-sc.com .](https://reader036.fdocuments.us/reader036/viewer/2022080915/56649de95503460f94ae3f17/html5/thumbnails/18.jpg)
Step 4: Establishing learning effects
DRIVERSstandards,
policiesMETHODS
e.g. planning, coordination, control
RESOURCESe.g. time, money, people, materials WORKING
ENVIRONMENTincidents
INTENTIONSManagement
ACTIONSSupervisors
CONSEQUENCESOperational staff
1: Single-loop learning2: Double-loop learning3: Triple-loop learning
1
23
![Page 19: Dominant underlying factors of work related accidents Chris Pietersen TNO Safety Solutions Consultants BV General manager pietersen@safety-sc.com .](https://reader036.fdocuments.us/reader036/viewer/2022080915/56649de95503460f94ae3f17/html5/thumbnails/19.jpg)
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.
![Page 20: Dominant underlying factors of work related accidents Chris Pietersen TNO Safety Solutions Consultants BV General manager pietersen@safety-sc.com .](https://reader036.fdocuments.us/reader036/viewer/2022080915/56649de95503460f94ae3f17/html5/thumbnails/20.jpg)
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.