Dominant underlying factors of work related accidents Chris Pietersen TNO Safety Solutions Consultants BV General manag

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

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

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 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.

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, people, materials DRIVERS 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.