Safety culture: Philosopher's stone or man of straw?

This introductory paper to the special issue on Safety Culture considers some of the key issues relating to the nature, measurement and utility of this concept. It argues that there are many important questions still unanswered: what is safety culture and what is its theoretical basis (the question of definition), is it synonymous with safety climate, what are the essential characteristics of a 'good' safety culture and how might they be best measured, what are the reliability, validity and utility of existing measures of safety culture, and how does the concept contribute-if at all-to good safety systems and performance? Can an organization's safety culture be related to additional parameters (such as accident and incident performance) which are judged both within and outside the organization by the full range of stake-holders? Finally, the authors consider future issues and the future direction of work in this area.     

Safety Regulations and the Uncertainty of Work-Related Road Accident Loss: The Triple Identity of Chinese Local Governments Under Principal–Agent Framework

This study examines how government safety regulations affect the uncertainty of work-related road accident loss (UWRAL) by considering the multi-identity of local governments in the relationship among the central government, the local governments, and enterprises. Fixed effects panel models and mediation analyses with bootstrapping were conducted to test the hypotheses using Chinese provincial panel data from 2008 to 2014. Given the complexity and nonlinear characteristics of road safety systems, a new approach based on self-organized criticality theory is proposed to measure the uncertainty of road accident loss from a complex system perspective. We find that a regional government with detailed safety work planning (SWP), high safety supervision intensity (SSI), and safety information transparency (SIT) can decrease the UWRAL. Furthermore, our findings suggest that SSI and SIT partially mediate the relationship between the SWP of regional governments and the UWRAL, with 19.7% and 23.6% indirect effects, respectively. This study also provides the government with managerial implications by linking the results of risk assessment to decision making for risk management.     

Participatory analysis of accidents and incidents as a tool for increasing safety behaviour in fishermen. A pilot intervention study

Although occupational accidents are common in fishery, safety work is often not given priority by the fishermen. The aims of this study were to test a group-based intervention for increased activity in safety work through group discussion of accident/incident experience; to study occurred incidents/accidents and how such events were managed; and to study intervention effects on activity in safety work, risk acceptance and perceived manageability of risks. A sample of men from five crews (11 men) of Swedish fishermen participated. The study had a one group pre-test-post-test design for questionnaire data. The emphasis was on qualitative information collected during the intervention and interviews. The results indicated that accident causes could be appraised as being unmanageable even when technical solutions were possible. Psychological factors may cause incidents not to be documented or discussed. Incident experience seldom leads to preventive measures. Interaction between structural, social and psychological factors seemed to explain this. Questionnaires, observations and interview data suggested that some increase in safety work took place during the intervention. After the discussions the participants perceived risks to be less manageable. The study indicated that, although sensitive to dropout, participative safety interventions in fishery are feasible and may be effective. A longer or more intensive intervention may be necessary in order to progress from problem orientation to action orientation.     

Participatory analysis of accidents and incidents as a tool for increasing safety behaviour in fishermen. A pilot intervention study

Abstract

Although occupational accidents are common in fishery, safety work is often not given priority by the fishermen. The aims of this study were to test a group-based intervention for increased activity in safety work through group discussion of accident/incident experience; to study occurred incidents/accidents and how such events were managed; and to study intervention effects on activity in safety work, risk acceptance and perceived manageability of risks. A sample of men from five crews (11 men) of Swedish fishermen participated. The study had a one group pre-test–post-test design for questionnaire data. The emphasis was on qualitative information collected during the intervention and interviews. The results indicated that accident causes could be appraised as being unmanageable even when technical solutions were possible. Psychological factors may cause incidents not to be documented or discussed. Incident experience seldom leads to preventive measures. Interaction between structural, social and psychological factors seemed to explain this. Questionnaires, observations and interview data suggested that some increase in safety work took place during the intervention. After the discussions the participants perceived risks to be less manageable. The study indicated that, although sensitive to dropout, participative safety interventions in fishery are feasible and may be effective. A longer or more intensive intervention may be necessary in order to progress from problem orientation to action orientation.     

Competing Failure Risk Analysis Using Evidence Theory

Safety systems are important components of high-consequence systems that are intended to prevent the unintended operation of the system and thus the potentially significant negative consequences that could result from such an operation. This presentation investigates and illustrates formal procedures for assessing the uncertainty in the probability that a safety system will fail to operate as intended in an accident environment. Probability theory and evidence theory are introduced as possible mathematical structures for the representation of the epistemic uncertainty associated with the performance of safety systems, and a representation of this type is illustrated with a hypothetical safety system involving one weak link and one strong link that is exposed to a high temperature fire environment. Topics considered include (1) the nature of diffuse uncertainty information involving a system and its environment, (2) the conversion of diffuse uncertainty information into the mathematical structures associated with probability theory and evidence theory, and (3) the propagation of these uncertainty structures through a model for a safety system to obtain representations in the context of probability theory and evidence theory of the uncertainty in the probability that the safety system will fail to operate as intended. The results suggest that evidence theory provides a potentially valuable representational tool for the display of the implications of significant epistemic uncertainty in inputs to complex analyses.     

Risk Prevention and Policy-Making in Automatic Systems

Accidents with automatic production systems are reported to be on the order of one in a hundred or thousand robot-years, while fatal accidents are found to occur one or two orders of magnitude less frequently. Traditions in occupational safety tend to seek for safety targets in terms of zero severe accidents for automatic systems. Decision-making requires a risk assessment balancing potential risk reduction measures and costs within the cultural environment of a production company. This paper presents a simplified procedure which acts as a decision tool. The procedure is based on a risk concept approaching prevention both in a deterministic and in a probabilistic manner. Eight accident scenarios are shown to represent the potential accident processes involving robot interactions with people. Seven prevention policies are shown to cover the accident scenarios in principle. An additional probabilistic approach may indicate which extra safety measures can be taken against what risk reduction and additional costs. The risk evaluation process aims at achieving a quantitative acceptable risk level. For that purpose, three risk evaluation methods are discussed with respect to reaching broad consensus on the safety targets.     

Benchmarking Safety Climate in Hazardous Environments: A Longitudinal, Interorganizational Approach

Safety climate is an important element of organizational reliability. This study applied benchmarking strategies for monitoring safety climate across nine North Sea oil and gas installations that were surveyed in consecutive years. Examination of absolute changes in safety climate complemented the benchmarking approach. Discriminant function analyses (DFA) identified the elements of safety climate predictive of self-reported accidents; correlational analyses were applied to the scale scores and accident proportions across the year period. Absolute improvements were substantial, with safety climate profiles converging in the second year. Large relative improvements were also observed. DFA highlighted perceived management commitment to safety and willingness to report accidents as significant predictors of personal accident involvement. Changes in perceived management commitment to safety were closely associated with changes in safety behavior.     

A Three‐Part Bayesian Network for Modeling Dwelling Fires and Their Impact upon People and Property

In the United Kingdom, dwelling fires are responsible for the majority of all fire‐related fatalities. The development of these incidents involves the interaction of a multitude of variables that combine in many different ways. Consequently, assessment of dwelling fire risk can be complex, which often results in ambiguity during fire safety planning and decision making. In this article, a three‐part Bayesian network model is proposed to study dwelling fires from ignition through to extinguishment in order to improve confidence in dwelling fire safety assessment. The model incorporates both hard and soft data, delivering posterior probabilities for selected outcomes. Case studies demonstrate how the model functions and provide evidence of its use for planning and accident investigation.     

Perception and control of occupational injury risks in fishery--a pilot study

The frequency of occupational accidents in fishery is high in most fishery nations. Implementation of safety measures has, however, been limited. The purpose of the present cross-sectional study was to explore Swedish fishermen's attitudes towards occupational risks and accident control. Information was acquired through a questionnaire distributed to a convenience sample of 92 fishermen. Indices were built, containing variables relevant to perceived risk levels in connection with work, perceived manageability of risks, activity in safety work, technical knowledge and individual attitudes towards risks. The results did not support earlier findings of low risk awareness and risk acceptance among fishermen. Perceived manageability of risks but not perceived risk level, accident experience or risk acceptance, were significantly associated with activity in safety work. The results suggest that safety work might benefit from efforts to develop fishermen's understanding of how the development of hazardous situations can be prevented or managed. The results do not support strategies for accident control in fishery based solely on increasing risk awareness.     

Evaluation of the Consequences of a Cistern Truck Accident While Transporting Dangerous Substances through a Tunnel

The transportation of dangerous substances by truck carriers harbors important safety issues in both road and mine tunnels. Even though traffic conditions in road and mine tunnels are different, the potential geometric and hydrodynamic similarities can lead to similar effects from the uncontrolled leakage of the dangerous material. This work was motivated by the design study of the LAGUNA‐LBNO (Large Apparatus studying Grand Unification and Neutrino Astrophysics and Long Baseline Neutrino Oscillations) project. The considered neutrino detector requires a huge amount of liquid argon, which must be transported down the tunnel. The present work focuses on the estimation of the most credible incident and the resulting consequences in the case of a truck accident in the tunnel. The approach and tools used in the present work are generic and can be adapted to other similar situations.     

Perception and control of occupational injury risks in fishery--a pilot study

The frequency of occupational accidents in fishery is high in most fishery nations. Implementation of safety measures has, however, been limited. The purpose of the present cross-sectional study was to explore Swedish fishermen's attitudes towards occupational risks and accident control. Information was acquired through a questionnaire distributed to a convenience sample of 92 fishermen. Indices were built, containing variables relevant to perceived risk levels in connection with work, perceived manageability of risks, activity in safety work, technical knowledge and individual attitudes towards risks. The results did not support earlier findings of low risk awareness and risk acceptance among fishermen. Perceived manageability of risks but not perceived risk level, accident experience or risk acceptance, were significantly associated with activity in safety work. The results suggest that safety work might benefit from efforts to develop fishermen's understanding of how the development of hazardous situations can be prevented or managed. The results do not support strategies for accident control in fishery based solely on increasing risk awareness.     

Coordinability and Consistency in Accident Causation and Prevention: Formal System Theoretic Concepts for Safety in Multilevel Systems

Although a “system approach” to accidents in sociotechnical systems has been frequently advocated, formal system theoretic concepts remain absent in the literature on accident analysis and system safety. To address this gap, we introduce the notions of coordinability and consistency from the hierarchical and multilevel systems theory literature. We then investigate the applicability and the importance of these concepts to accident causation and safety. Using illustrative examples, including the worst disaster in aviation history, and recent incidents in the United States of aircraft clipping each other on the tarmac, we propose that the lack of coordinability is a fundamental failure mechanism causing or contributing to accidents in multilevel systems. We make a similar case for the lack of consistency. Coordinability and consistency become ingredients for accident prevention, and their absence fundamental failure mechanisms that can lead to system accidents. Finally, using the concepts introduced in this work, we identify several venues for further research, including the development of a theory of coordination in multilevel systems, the investigation of potential synergies between coordinability, consistency, and the high reliability organizations paradigm, and the possibility of reframing the view that “sloppy management is the root cause of many industrial accidents” as one of lack of coordinability and/or consistency between management and operations. By introducing and expanding on the concepts of coordinability and consistency, we hope to contribute to the thinking about, and the to language of, accident causation, and prevention and to add to the intellectual toolkit of safety professionals and academics.     

Interpreting MSHA Citations Through the Lens of Occupational Health and Safety Management Systems: Investigating Their Impact on Mine Injuries and Illnesses 2003–2010

Since the late 1980s, the U.S. Department of Labor has considered regulating a systems approach to occupational health and safety management. Recently, a health and safety management systems (HSMS) standard has returned to the regulatory agenda of both the Occupational Safety and Health Administration (OSHA) and the Mine Safety and Health Administration (MSHA). Because a mandated standard has implications for both industry and regulating bodies alike, it is imperative to gain a greater understanding of the potential effects that an HSMS regulatory approach can have on establishment‐level injuries and illnesses. Through the lens of MSHA's regulatory framework, we first explore how current enforcement activities align with HSMS elements. Using MSHA data for the years 2003–2010, we then analyze the relationship between various types of enforcement activities (e.g., total number of citations, total penalty amount, and HSMS‐aligned citations) and mine reportable injuries. Our findings show that the reduction in mine reportable injuries predicted by increases in MSHA enforcement ranges from negligible to 18%. The results suggest that the type and focus of the enforcement activity may be more important for accident reduction than the total number of citations issued and the associated penalty amount.     

Decision Making During Nuclear Power Plant Incidents—A New Approach to the Evaluation of Precursor Events

Renewed interest in precursor analysis has shown that the evaluation of near misses is an interdisciplinary effort, fundamental within the life of an organization for reducing operational risks and enabling accident prevention. The practice of precursor analysis has been a part of nuclear power plant regulation in the United States for over 25 years. During this time, the models used in the analysis have evolved from simple risk equations to quite complex probabilistic risk assessments. But, one item that has remained constant over this time is that the focus of the analysis has been on modeling the scenario using the risk model (regardless of the model sophistication) and then using the results of the model to determine the severity of the precursor incident. We believe that evaluating precursors in this fashion could be a shortcoming since decision making during the incident is not formally investigated. Consequently, we present the idea for an evaluation procedure that enables one to integrate current practice with the evaluation of decisions made during the precursor event. The methodology borrows from technologies both in the risk analysis and the decision analysis realms. We demonstrate this new methodology via an evaluation of a U.S. precursor incident. Specifically, the course of the incident is represented by the integration of a probabilistic risk assessment model (i.e., the risk analysis tool) with an influence diagram and the corresponding decision tree (i.e., the decision analysis tools). The results and insights from the application of this new methodology are discussed.     

Textual data transformations using natural language processing for risk assessment

Underlying information about failure, including observations made in free text, can be a good source for understanding, analyzing, and extracting meaningful information for determining causation. The unstructured nature of natural language expression demands advanced methodology to identify its underlying features. There is no available solution to utilize unstructured data for risk assessment purposes. Due to the scarcity of relevant data, textual data can be a vital learning source for developing a risk assessment methodology. This work addresses the knowledge gap in extracting relevant features from textual data to develop cause–effect scenarios with minimal manual interpretation. This study applies natural language processing and text-mining techniques to extract features from past accident reports. The extracted features are transformed into parametric form with the help of fuzzy set theory and utilized in Bayesian networks as prior probabilities for risk assessment. An application of the proposed methodology is shown in microbiologically influenced corrosion-related incident reports available from the Pipeline and Hazardous Material Safety Administration database. In addition, the trained named entity recognition (NER) model is verified on eight incidents, showing a promising preliminary result for identifying all relevant features from textual data and demonstrating the robustness and applicability of the NER method. The proposed methodology can be used in domain-specific risk assessment to analyze, predict, and prevent future mishaps, ameliorating overall process safety.     

Psychosocial factors and safety behaviour as predictors of accidental work injuries in farming

Farming is one of the most hazardous occupations in terms of the incidence and seriousness of accidental injuries. Research with other occupational groups has drawn attention to the role of psychosocial factors and stress. Such research needs to be extended to agriculture. Since stress may be a problem faced by farmers, there is a particular need to investigate the associations between farm accidents and work stressors and stress reactions. Using multivariate logistic regression analyses, this study aimed to uncover the best psychosocial predictors of injury, while controlling for exposure-related confounders. From a randomly selected sample of 794 farms, 10% of all farms in Ringkoebing County, Denmark, 393 farmers completed completed weekly accident registration over 12 months. The study sample consisted of 310 farmers who also completed questionnaires on psychosocial factors. Results indicated that farm stressors (including perceived economic problems), stress symptoms, and safety behaviour were predictors of occupational farm accidents. Higher levels of stressors and stress symptoms and poor safety behaviour were all associated with an elevated risk of injury. In the case of stress symptoms, the relation with accidents occurred via an interaction with safety behaviour. The combination of high levels of stress symptoms and poor safety behaviour was associated with a particularly high accident risk.     

Risk-Based Ranking of Dominant Contributors to Maritime Pollution Events

This report describes a conceptual approach for identifying dominant contributors to risk from maritime shipping of hazardous materials. Maritime transportation accidents are relatively common occurrences compared to more frequently analyzed contributors to public risk. Yet research on maritime safety and pollution incidents has not been guided by a systematic, risk-based approach. Maritime shipping accidents can be analyzed using event trees to group the accidents into "bins," or groups, of similar characteristics such as type of cargo, location of accident (e.g., harbor, inland waterway), type of accident (e.g., fire, collision, grounding), and size of release. The importance of specific types of events to each accident bin can be quantified. Then the overall importance of accident events to risk can be estimated by weighting the events' individual bin importance measures by the risk associated with each accident bin.     

Scale invariance of incident size distributions in response to sizes of their causes.

Incidents can be defined as low-probability, high-consequence events and lesser events of the same type. Lack of data on extremely large incidents makes it difficult to determine distributions of incident size that reflect such disasters, even though they represent the great majority of total losses. If the form of the incident size distribution can be determined, then predictive Bayesian methods can be used to assess incident risks from limited available information. Moreover, incident size distributions have generally been observed to have scale invariant, or power law, distributions over broad ranges. Scale invariance in the distributions of sizes of outcomes of complex dynamical systems has been explained based on mechanistic models of natural and built systems, such as models of self-organized criticality. In this article, scale invariance is shown to result also as the maximum Shannon entropy distribution of incident sizes arising as the product of arbitrary functions of cause sizes. Entropy is shown by simulation and derivation to be maximized as a result of dependence, diversity, abundance, and entropy of multiplicative cause sizes. The result represents an information-theoretic explanation of invariance, parallel to those of mechanistic models. For example, distributions of incident size resulting from 30 partially dependent causes are shown to be scale invariant over several orders of magnitude. Empirical validation of power law distributions of incident size is reviewed, and the Pareto (power law) distribution is validated against oil spill, hurricane, and insurance data. The applicability of the Pareto distribution, in particular, for assessment of total losses over a planning period is discussed. Results justify the use of an analytical, predictive Bayesian version of the Pareto distribution, derived previously, to assess incident risk from available data.     

Improving Risk Management: From Lame Excuses to Principled Practice

The three classic pillars of risk analysis are risk assessment (how big is the risk and how sure can we be?), risk management (what shall we do about it?), and risk communication (what shall we say about it, to whom, when, and how?). We propose two complements as important parts of these three bases: risk attribution (who or what addressable conditions actually caused an accident or loss?) and learning from experience about risk reduction (what works, and how well?). Failures in complex systems usually evoke blame, often with insufficient attention to root causes of failure, including some aspects of the situation, design decisions, or social norms and culture. Focusing on blame, however, can inhibit effective learning, instead eliciting excuses to deflect attention and perceived culpability. Productive understanding of what went wrong, and how to do better, thus requires moving past recrimination and excuses. This article identifies common blame‐shifting “lame excuses” for poor risk management. These generally contribute little to effective improvements and may leave real risks and preventable causes unaddressed. We propose principles from risk and decision sciences and organizational design to improve results. These start with organizational leadership. More specifically, they include: deliberate testing and learning—especially from near‐misses and accident precursors; careful causal analysis of accidents; risk quantification; candid expression of uncertainties about costs and benefits of risk‐reduction options; optimization of tradeoffs between gathering additional information and immediate action; promotion of safety culture; and mindful allocation of people, responsibilities, and resources to reduce risks. We propose that these principles provide sound foundations for improving successful risk management.