Identifying pan-industry common contributors to major accident events

2020 ◽  
Vol 60 (1) ◽  
pp. 41
Author(s):  
Joelle Mitchell ◽  
Alice Turnbull
Keyword(s):  
Human Error ◽  
Multidisciplinary Approach ◽  
Error Management ◽  
Causal Factors ◽  
Incident Investigation ◽  
Safety Research ◽  
Single Lens ◽  
Major Accident ◽  
Proactive Measures ◽  
Culture And Climate

Analysis of incident investigation findings as a means of identifying common precursors or causal factors is a common topic of safety research. Historically this type of research has been conducted through a single lens, depending on the researcher’s discipline, with incidents analysed in accordance with a favoured theory, or grouped according to industry or region. This has led to the development of numerous frameworks and taxonomies that attempt to predict or analyse events at various levels of granularity. Such theories and disciplines include safety culture and climate, human factors, human error, management systems, systems theory, engineering and design, chemistry and maintenance. The intent of such research is ostensibly to assist organisations in understanding the degree to which their operations are vulnerable to known precursors or causal factors to major accident events and to take proactive measures to improve the safety of their operations. However, the discipline-specific nature of much of this research may limit its application in practice. Specific frameworks and taxonomies may be of assistance when organisations have identified a relevant area of vulnerability within their operations, but are unlikely to assist organisations in identifying those vulnerabilities in the first place. This paper seeks to fill that gap. A multidisciplinary approach was taken to identify common causal factors. Investigation reports published by independent investigation agencies across various industries were analysed to determine common causal factors regardless of discipline or industry.

Research to Determine the Frequency and Cause of Injury Accidents in Underground Mining

1987 ◽  
Vol 31 (8) ◽  
pp. 926-930
Author(s):  
Brian E. Shaw ◽  
Mark S. Sanders
Keyword(s):  
Human Error ◽  
Systems Approach ◽  
Underground Mining ◽  
Causal Chain ◽  
Causal Factors ◽  
Relative Contribution ◽  
Accident Case

A systems approach was used to investigate 188 underground mining accidents. A team of raters assessed the relative contribution of 10 causal factors in each accident case. The results illustrate the importance of human error and management in the causal chain of accidents.

scholarly journals Patient safety: understanding human error in intensive nursing care

2018 ◽  
Vol 52 (0) ◽  
Author(s):  
Sabrina da Costa Machado Duarte ◽  
Marluci Andrade Conceição Stipp ◽  
Maria Manuela Vila Nova Cardoso ◽  
Andreas Büscher
Keyword(s):  
Intensive Care ◽  
Nursing Care ◽  
Human Error ◽  
Participant Observation ◽  
Quality Care ◽  
Hospital Data ◽  
Nursing Team ◽  
Proactive Measures ◽  
Intensive Care Nursing ◽  
Care Nursing

ABSTRACT Objective: To analyze the active failures and the latent conditions related to errors in intensive nursing care and to discuss the reactive and proactive measures mentioned by the nursing team. Method: Qualitative, descriptive, exploratory study conducted at the Intensive Care Unit of a general hospital. Data were collected through interviews, participant observation and submitted to lexical analysis in the ALCESTE® software and to ethnographic analysis. Results: 36 professionals of the nursing team participated in the study. The analysis originated three lexical classes: Error in intensive care nursing; Active failures and latent conditions related to errors in the intensive care nursing team; Reactive and proactive measures adopted by the nursing team regarding errors in intensive care. Conclusion: Reactive and proactive measures influenced the safety culture, in particular, the recognition of errors by professionals, contributing to their prevention, safety and quality care.

scholarly journals Incident Causal Factors and the Reasons for Conducting Investigations: A Study of Five Ghanaian Large-Scale Mines

Safety ◽  
2020 ◽  
Vol 6 (1) ◽  
pp. 9 ◽  
Author(s):  
Eric Stemn ◽  
Florence Ntsiful ◽  
Marconi Afenyo Azadah ◽  
Theophilus Joe-Asare
Keyword(s):  
Large Scale ◽  
Mining Industry ◽  
Causal Factor ◽  
Organizational Safety ◽  
Causal Factors ◽  
Incident Investigation ◽  
Double Loop Learning ◽  
Significant Difference ◽  
Two Factors ◽  
Questionnaire Surveys

Background: This research sought to understand the perspective of mineworkers regarding incident investigations, with the objective of identifying incident investigations improvement opportunities. First, through interviews, the research sought to identify the causal factors considered during investigations and the reasons for conducting investigations in the Ghanaian mining industry. Secondly, through questionnaire surveys, the study focused on understanding the extent to which a large sample of mineworkers considered the identified causal factors and investigation reasons relevant and applicable in their mine. Method: Data were collected from 41 participants through interviews and 659 respondents through surveys, and the data were analyzed through thematic, content, and statistical analyses, including descriptive statistics, one-way ANOVA, and correlation analysis. Result: The interviews led to the identification of five and nine categories of incident causal factors and reasons for investigating incidents, respectively. The results suggested a focus on workers’ unsafe acts as the main incident causal factor and identifying the person who caused the incident as one of the major reasons for investigating incidents, as these two factors where the modal choice from both the interviews and survey across all five mines. The results further showed that concerning the accident causal factors and the reasons for investigating incidents, no significant difference was observed between the perspectives of mineworkers involved in investigations and mineworkers with no investigation responsibilities. Conclusion: It can be concluded from the results that talking to ordinary mineworkers does not generate innovative safety responses in this context, as the workers believe whatever they are taught, without critiquing it. Again, the focus on workers’ behavior as an accident causal factor is an indication of single-loop learning in contrast to double-loop learning, and its implication as well as opportunities to strengthen incident investigation focusing on improving organizational safety have been discussed.

Based on Human Behavior Process of Human Error Defensive Management Research for NPP

2017 ◽  
Author(s):  
Shen Yang ◽  
Geng Bo ◽  
Li Dan
Keyword(s):  
Power Plant ◽  
Nuclear Power Plant ◽  
Control Chart ◽  
Human Behavior ◽  
Nuclear Power ◽  
Human Error ◽  
Human Performance ◽  
Human Factor ◽  
Error Management ◽  
Root Cause

According to the research of nuclear power plant human error management, it is found that the traditional human error management are mainly based on the result of human behavior, the event as the point cut of management, there are some drawbacks. In this paper, based on the concept of the human performance management, establish the defensive human error management model, the innovation point is human behavior as the point cut, to reduce the human errors and accomplish a nip in the bud. Based on the model, on the one hand, combined with observation and coach card, to strengthen the human behavior standards expected while acquiring structured behavior data from the nuclear power plant production process; on the other hand, combined with root cause analysis method, obtained structured behavior data from the human factor event, thus forming a human behavior database that show the human performance state picture. According to the data of human behavior, by taking quantitative trending analysis method, the P control chart of observation item and the C control chart of human factor event is set up by Shewhart control chart, to achieve real-time monitoring of the process and result of behavior. At the same time, development Key Performance Indicators timely detection of the worsening trend of human behavior and organizational management. For the human behavior deviation and management issues, carry out the root cause analysis, to take appropriate corrective action or management improvement measures, so as to realize the defense of human error, reduce human factor event probability and improve the performance level of nuclear power plant.

Commercializing an Automatically Deployable Rollover Protective Structure (AutoROPS) for a Zero-Turn Riding Mower: Initial Product Safety Assessment Criteria

2004 ◽  
Author(s):  
J. R. Etherton ◽  
E. A. McKenzie ◽  
J. R. Powers
Keyword(s):  
Electromagnetic Interference ◽  
High Speed ◽  
Safety Assessment ◽  
Human Error ◽  
Product Safety ◽  
Current Phase ◽  
Protective Structure ◽  
Private Industry ◽  
Cooperative Effort ◽  
Safety Research

Fatal injuries have occurred to operators of zero-turn riding mowers when these machines rolled over during high speed sharp turns or on uneven terrain. These mowers are frequently operated in low clearance conditions such as around trees and when loaded onto low-roofed trailers. The automatically deployable rollover protective structure (AutoROPS) can provide both protection during rollover events and the capability to operate a mower in low clearance conditions. Until recently, AutoROPS technology development has occurred only in a government laboratory. In the current phase of development, private industry has taken an interest in the AutoROPS technology and is pursuing, with NIOSH, the product testing and development needed to commercialize the AutoROPS on a zero-turn riding mower. The government’s role, as a partner with private industry in bringing new safety technology into practical application, is discussed. Importantly, for the AutoROPS product to be as effective as possible, it should not introduce additional, unacceptable risks. Previous product safety assessments led by government laboratories are reviewed. These assessments were made to minimize hazards in products developed in government labs. A product safety assessment was performed on the AutoROPS during its design phase. In addition to minimizing the severity and frequency of operator injury resulting from an accidental rollover, the assessment considered 1) environmental factors such as corrosion, electromagnetic interference, and vibration; 2) human error avoidance; and 3) safeguard reliability analysis. This assessment was a cooperative effort between the safety engineering design team at the Division of Safety Research of the National Institute for Occupational Safety and Health; a ROPS manufacturer; and a zero-turn riding mower manufacturer. Design features are being incorporated into the prototype AutoROPS to address hazards encountered in normal use of these machines.

scholarly journals A Causal Model to Design more Effective Policies and Practices in Error Management in the Healthcare Industry

2021 ◽  
Keyword(s):  
Safety Culture ◽  
Medical Error ◽  
Evaluation Method ◽  
Information Access ◽  
Fuzzy Decision Making ◽  
Error Management ◽  
Causal Relationships ◽  
Factors Affecting ◽  
Culture And Climate ◽  
Policies And Practices

Background: Identification of the factors contributing to the errors of medical staff and examining the causal relationships among those factors can help better manage and design more effective policies and practices. Objectives: This study aimed to identify the causes and factors affecting medical error management and determine a model for better management of such errors. Methods: This descriptive-analytical study was conducted in two qualitative and quantitative phases. In the quantitative part of the study, the factors related to medical error management were identified and validated through reviewing previous studies and interviewing some specialists. Following that, the fuzzy decision-making trial and evaluation method was used for structural modeling of the factors and investigating the causal relationships among them in the quantitative part. Results: In this study, the results showed that the "education and learning from error" subfactor had the most significant impact on the system. The second highly effective subfactors in the management of medical errors were "organizational communication and improved information access", "safety culture and climate", and "policies, procedures, and guidelines". In addition, the "safety culture and climate" was the most important factor that had the most critical impact on the system. Moreover, the "handoff conversations and communication" subfactor was mostly influenced by the other factors, followed by the "incident reporting system", "error prevention and corrective measures", "safety culture and climate", and "individuals' participation". Conclusions: According to the results of this study, the health care industry should take into consideration both organizational and individual factors in error management. In order to achieve better planning and higher performance in error management, increase patient safety, and ultimately improve the quality of hospital services, it is suggested to consider the causes and factors affecting the system.

scholarly journals Application of Integrated Human Error Management in Human Factors Engineering Process to Nuclear Power Plant Design

2021 ◽  
Vol 6 (4) ◽  
pp. 1186-1198
Author(s):  
Kenji Mashio ◽  
Kodo Ito
Keyword(s):  
Power Plant ◽  
Nuclear Power Plant ◽  
Human Factors ◽  
Nuclear Power ◽  
Human Error ◽  
Error Management ◽  
Human Factors Engineering ◽  
Plant Design ◽  
Integrated Process ◽  
Human Errors

Integrated process of human error management in human factors engineering (HFE) process provides a systematic direction for the design countermeasures development to prevent potential human errors. The process analyzes performance influence factors (PIFs) for crew failure modes (CFMs) and human failure events (HFEvs) in human reliability analysis (HRA). This paper provides applications of the process to the event evaluation for nuclear power plant design, especially PWR. In this application, the HRA/HFE integrated process had specified further detail for PIF attributes which had not been obtained in HRA, and showed further investigations to treat how operators induced their human errors through their cognitive task process in their work environment. This application showed effectiveness of the process in order to provide design countermeasures for preventing potential human errors occurrence based on the extensive PIFs and their error forcing context in HRA.

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