Assessing and Preventing Serious Incidents with Behavioral Science: Enhancing Heinrich’s Triangle for the 21st Century

ABSTRACT

The rate of occupational injuries has been declining annually, but the rate of decline for fatalities has not kept a similar pace. Behavior-based safety (BBS) contributes to reducing personal injuries, and can be applied to preventing serious incidents. To address serious injuries with greater confidence requires a change in perspective on the causes of fatalities and serious injuries. Heinrich’s safety triangle helps describe the ratio between minor incidents and major incidents, but is not adequate in helping to predict serious incidents. Adding a special subset to the safety triangle can assist safety practitioners in predicting and influencing such events. Extending the triangle to include more foundational root causes, such as leadership shortcomings and system failures, will expand the scope of the behavior analysis, and including greater specificity about the precursors to serious incidents will help the precision of the behavior analysis. The implications of the expanded triangle for amplifying the effectiveness of BBS for reducing serious incidents are discussed.     

Out of sight and out of mind? A literature review of occupational safety and health leadership and management of distributed workers

Distributed workers – those who work autonomously and remotely from their organisation’s main locations for at least some of their work-time – are an important and growing proportion of the workforce that share common characteristics of temporal and spatial distance. Yet, many leadership styles and management practices assume face-to-face interaction, potentially rendering them less helpful in trying to ensure good occupational safety and health (OSH) outcomes for distributed workers. We conducted a systematic literature review to examine the leadership and management of OSH for distributed workers. Twenty-three papers were identified. Eleven papers identified established leadership styles, including leader-member exchange, (safety specific) transformational and considerate leadership. Twenty papers examined management. Findings from these 20 papers were interpreted as representing resources, deployed through management and utilised by managers to ensure OSH for distributed workers, including communication technologies, social support and a good safety climate. Despite limited research in this area, findings indicate the importance of both leadership and management in ensuring OSH for distributed workers. Findings suggest a fertile area for future enquiry.     

Consumer Confidence in the Safety of Food and Newspaper Coverage of Food Safety Issues: A Longitudinal Perspective

This study develops a longitudinal perspective on consumer confidence in the safety of food to explore if, how, and why consumer confidence changes over time. In the first study, a theory-based monitoring instrument for consumer confidence in the safety of food was developed and validated. The monitoring instrument assesses consumer confidence together with its determinants. Model and measurement invariance were validated rigorously before developments in consumer confidence in the safety of food and its determinants were investigated over time. The results from the longitudinal analysis show that across four waves of annual data collection (2003–2006), the framework was stable and that the relative importance of the determinants of confidence was, generally, constant over time. Some changes were observed regarding the mean ratings on the latent constructs. The second study explored how newspaper coverage of food safety related issues affects consumer confidence in the safety of food through subjective consumer recall of food safety incidents. The results show that the newspaper coverage on food safety issues is positively associated with consumer recall of food safety incidents, both in terms of intensity and recency of media coverage.     

考虑追溯水平的食品厂商竞争决策研究

本文综合考虑食品市场竞争环境,消费者食品安全风险规避程度及食品追溯水平等因素建立了食品厂商的双寡头竞争博弈模型,探讨了食品的追溯水平与消费者风险规避程度对食品厂商价格、安全努力水平以及利润的影响。研究发现：食品厂商的最优价格和食品的安全努力水平随其食品追溯水平的提高而增加,随竞争厂商的食品追溯水平的提高而降低;厂商食品追溯水平较高时,其安全努力水平随消费者风险规避程度的增大而提高,其最优价格随高风险规避型消费者比例的增大而增加;而厂商食品追溯水平较低时,其安全努力水平随消费者风险规避程度的增大先增加而后下降,其最优价格随高风险规避型消费者比例的增大总是下降;随高风险规避型消费者比例的增大,各厂商的食品追溯水平对其决策的影响产生不同的变化。     

The Implementation and Maintenance of a Behavioral Safety Process in a Petroleum Refinery

A values-centered and team-based behavioral safety process was implemented in a petroleum oil refinery. Employee teams defined the refinery's safety values and related practices, which were used to guide the process design and implementation. The process included (a) a safety assessment; (b) the clarification of safety-related values and related practices; (c) process design and executive overview; (d) safety-observation training; (e) feedback, recognition, and celebration; and (f) process maintenance. Data that span 20 years are presented to show the long-term impact on recordable incidents, lost-time cases, and direct costs of injuries. The implementation was associated with an 81% decrease in recordable incidents, a 79% decrease in lost-time cases, and a 97% savings in annual workers' compensation costs over an eight-year period. An interview with the vice president of the refinery is presented to highlight the process's influence on the refinery's safety culture.     

Optimizing Risk Analysis Relating to External Safety in The Netherlands

Risk analyses in The Netherlands have been optimized so that they now express risks in a numerical form suitable for comparison to national safety standards. This factor is more important to national government than to local authorities; other factors relevant for local authorities are given less emphasis or even completely omitted from the results of the analysis. From a comparison of 16 risk analyses carried out during the last decade, it became clear that in the last 5 years the methods of risk analyses related to external safety have become unified. Results are now presented in terms of individual risk contours and in terms of F-N curves (accident frequency vs. exceeded number of fatalities). This unification seems to be a result of government policy. First, the implementation of the post-Seveso-directive (501/82/EC) in The Netherlands obliges a number of industries to provide the authorities with a quantitative risk assessment. Second, the government has set standards for the maximum permissible risk in residential areas. A unified type of risk analysis is a tool to achieve both these policies. From interviews with local government authorities, however, it has become clear that they need and use some quantitative risk information that is not provided by the unified analysis. They feel they need figures that provide insight into the effects of incidents and into the way effects may change as a result of safety measures. Ultimately, government policy may mean that local officials receive less information than before.     

Sizing Inventory When Lead Time and Demand are Correlated

Determining appropriate inventory levels has been a subject of interest for both researchers and practitioners. Standard practice is to treat lead time demand as a random sum of random numbers and rely on established probability theory to calculate both reorder point and safety stock levels. A key assumption in these calculations, however, is that lead time and demand are not correlated. In this paper, we first explore situations where this assumption is untrue and then develop equations to determine the reorder point and the safety stock when lead time and demand are correlated. More specifically, we (1) derive formulas for the average and variance of the demand in a lead time, which can then be used to calculate the reorder point and the safety stock, (2) apply these formulas to two distributions for which there is a closed‐form solution: normal and Poisson, and (3) examine the effect of correlation on safety stock requirements under the normal distribution.     

Online patient feedback as a safety valve: An automated language analysis of unnoticed and unresolved safety incidents

Safety reporting systems are widely used in healthcare to identify risks to patient safety. But, their effectiveness is undermined if staff do not notice or report incidents. Patients, however, might observe and report these overlooked incidents because they experience the consequences, are highly motivated, and independent of the organization. Online patient feedback may be especially valuable because it is a channel of reporting that allows patients to report without fear of consequence (e.g., anonymously). Harnessing this potential is challenging because online feedback is unstructured and lacks demonstrable validity and added value. Accordingly, we developed an automated language analysis method for measuring the likelihood of patient-reported safety incidents in online patient feedback. Feedback from patients and families (n = 146,685, words = 22,191,427, years = 2013–2019) about acute NHS trusts (hospital conglomerates; n = 134) in England were analyzed. The automated measure had good precision (0.69) and excellent recall (0.98) in identifying incidents; was independent of staff-reported incidents (r = −0.04 to 0.19); and was associated with hospital-level mortality rates (z = 3.87; p < 0.001). The identified safety incidents were often reported as unnoticed (89%) or unresolved (21%), suggesting that patients use online platforms to give visibility to safety concerns they believe have been missed or ignored. Online stakeholder feedback is akin to a safety valve; being independent and unconstrained it provides an outlet for reporting safety issues that may have been unnoticed or unresolved within formal channels.     

A Discourse on the Incorporation of Organizational Factors into Probabilistic Risk Assessment: Key Questions and Categorical Review

This article presents a discourse on the incorporation of organizational factors into probabilistic risk assessment (PRA)/probabilistic safety assessment (PSA), a topic of debate since the 1980s that has spurred discussions among industry, regulatory agencies, and the research community. The main contributions of this article include (1) identifying the four key open questions associated with this topic; (2) framing ongoing debates by considering differing perspectives around each question; (3) offering a categorical review of existing studies on this topic to justify the selection of each question and to analyze the challenges related to each perspective; and (4) highlighting the directions of research required to reach a final resolution for each question. The four key questions are: (I) How significant is the contribution of organizational factors to accidents and incidents? (II) How critical, with respect to improving risk assessment, is the explicit incorporation of organizational factors into PRA? (III) What theoretical bases are needed for explicit incorporation of organizational factors into PRA? (IV) What methodological bases are needed for the explicit incorporation of organizational factors into PRA? Questions I and II mainly analyze PRA literature from the nuclear domain. For Questions III and IV, a broader review and categorization is conducted of those existing cross-disciplinary studies that have evaluated the effects of organizational factors on safety (not solely PRA-based) to shed more light on future research needs.     

Behavioral Safety in the Food Services Industry: Challenges and Outcomes

During the course of a 6-year behavioral safety consult at a food and drink industry site, data were collected on the number of Occupational Safety Health Administration (OSHA) recordable incidents, number of lost and restricted days, and number of peer safety observations. Employees were trained to identify safe and unsafe behavior, conduct peer observations, and provide peer feedback. Data collected from observations were utilized to deliver graphic feedback. Managers were encouraged to review graphic feedback with employees weekly, provide prompts for observation, and praise employees for conducting observations. A committee composed of employees and managers met monthly to address safety concerns. Reductions in incidents were observed over the course of the behavioral safety intervention, but a reversal to baseline could not be implemented. A negative correlation was observed between number of peer observations and number of recordable incidents. Results suggest that when employees conduct peer observations more frequently, the number of recordable incidents decreases.     

Process Safety Behavioral Systems: Behaviors Interlock in Complex Metacontingencies

ABSTRACT

This paper seeks to identify behavioral components active in process safety. Three types of behavior classes are identified as contributors to process safety: task-specific behaviors, safety-directed behaviors, and behaviors associated with situational awareness. Behavioral systems analysis is used to provide a framework for identifying the cross-functional interlocking behavioral contingencies that can, even over a period of years, contribute to process safety incidents. Leadership behaviors are also identified that can create the context in the form of metacontingencies that maintain these interlocking contingencies.     

Aging and Cardiometabolic Risk in European HEMS Pilots: An Assessment of Occupational Old‐Age Limits as a Regulatory Risk Management Strategy

Old‐age limits are imposed in some occupations in an effort to ensure public safety. In aviation, the “Age 60 Rule” limits permissible flight operations conducted by pilots aged 60 and over. Using a retrospective cohort design, we assessed this rule's validity by comparing age‐related change rates of cardiometabolic incapacitation risk markers in European helicopter emergency medical service (HEMS) pilots near age 60 with those in younger pilots. Specifically, individual clinical, laboratory, and electrocardiogram (ECG)‐based risk markers and an overall cardiovascular event risk score were determined from aeromedical examination records of 66 German, Austrian, Polish, and Czech HEMS pilots (average follow‐up 8.52 years). Risk marker change rates were assessed using linear mixed models and generalized additive models. Body mass index increases over time were slower in pilots near age 60 compared to younger pilots, and fasting glucose levels increased only in the latter. Whereas the lipid profile remained unchanged in the latter, it improved in the former. An ECG‐based arrhythmia risk marker increased in younger pilots, which persisted in the older pilots. Six‐month risk of a fatal cardiovascular event (in or out of cockpit) was estimated between 0% and 0.3%. Between 41% and 95% of risk marker variability was due to unexplained time‐stable between‐person differences. To conclude, the cardiometabolic risk marker profile of HEMS pilots appears to improve over time in pilots near age 60, compared to younger pilots. Given large stable interindividual differences, we recommend individualized risk assessment of HEMS pilots near age 60 instead of general grounding.     

Risk Management of Domino Effects Considering Dynamic Consequence Analysis

Domino effects are low‐probability high‐consequence accidents causing severe damage to humans, process plants, and the environment. Because domino effects affect large areas and are difficult to control, preventive safety measures have been given priority over mitigative measures. As a result, safety distances and safety inventories have been used as preventive safety measures to reduce the escalation probability of domino effects. However, these safety measures are usually designed considering static accident scenarios. In this study, we show that compared to a static worst‐case accident analysis, a dynamic consequence analysis provides a more rational approach for risk assessment and management of domino effects. This study also presents the application of Bayesian networks and conflict analysis to risk‐based allocation of chemical inventories to minimize the consequences and thus to reduce the escalation probability. It emphasizes the risk management of chemical inventories as an inherent safety measure, particularly in existing process plants where the applicability of other safety measures such as safety distances is limited.     

Towards a Fuzzy Bayesian Network Based Approach for Safety Risk Analysis of Tunnel‐Induced Pipeline Damage

Tunneling excavation is bound to produce significant disturbances to surrounding environments, and the tunnel‐induced damage to adjacent underground buried pipelines is of considerable importance for geotechnical practice. A fuzzy Bayesian networks (FBNs) based approach for safety risk analysis is developed in this article with detailed step‐by‐step procedures, consisting of risk mechanism analysis, the FBN model establishment, fuzzification, FBN‐based inference, defuzzification, and decision making. In accordance with the failure mechanism analysis, a tunnel‐induced pipeline damage model is proposed to reveal the cause‐effect relationships between the pipeline damage and its influential variables. In terms of the fuzzification process, an expert confidence indicator is proposed to reveal the reliability of the data when determining the fuzzy probability of occurrence of basic events, with both the judgment ability level and the subjectivity reliability level taken into account. By means of the fuzzy Bayesian inference, the approach proposed in this article is capable of calculating the probability distribution of potential safety risks and identifying the most likely potential causes of accidents under both prior knowledge and given evidence circumstances. A case concerning the safety analysis of underground buried pipelines adjacent to the construction of the Wuhan Yangtze River Tunnel is presented. The results demonstrate the feasibility of the proposed FBN approach and its application potential. The proposed approach can be used as a decision tool to provide support for safety assurance and management in tunnel construction, and thus increase the likelihood of a successful project in a complex project environment.     

INTELLECTUAL PROPERTY RIGHTS POLICY,COMPETITION AND INNOVATION

To what extent and in what form should the intellectual property rights (IPR) of innovators be protected? Should a company with a large technology lead over its rivals receive the same IPR protection as a company with a more limited advantage? In this paper, we develop a dynamic framework for the study of the interactions between IPR and competition, in particular to understand the impact of such policies on future incentives. The economy consists of many industries and firms engaged in cumulative (step‐by‐step) innovation. IPR policy regulates whether followers in an industry can copy the technology of the leader. We prove the existence of a steady‐state equilibrium and characterize some of its properties. We then quantitatively investigate the implications of different types of IPR policy on the equilibrium growth rate and welfare. The most important result from this exercise is that full patent protection is not optimal; instead, optimal policy involves state‐dependent IPR protection, providing greater protection to technology leaders that are further ahead than those that are close to their followers. This is because of a trickle‐down effect: providing greater protection to firms that are further ahead of their followers than a certain threshold increases the R&D incentives also for all technology leaders that are less advanced than this threshold.     

Flexible Backup Supply and the Management of Lead‐Time Uncertainty

We consider replenishment decisions for a constant rate demand environment from a supplier with uncertain lead times. We study the potential use of a flexible backup supplier as an emergency response to accurate lead‐time information arriving at (or close after) the beginning of the demand interval and well after an original order with the stochastic lead‐time supplier has been placed. The emergency response decisions involve whether to order and how much from the flexible backup supplier, with the objective of minimizing the cost of meeting demand. We derive the optimal emergency‐response policy and clearly outline its implications on the optimized safety lead time of the original order placement and on the cost of meeting demand. We examine the impact on the use of the flexible backup supplier of factors like the arrival time of accurate lead‐time information and the response lead time of the backup supplier. We further study the potential benefits of the use of the flexible backup supplier in a dual role: as one of the two suppliers in a redundant supply system assigned to originally meet the demand and as an emergency response to later‐arriving lead‐time information. Our numerical studies illustrate the benefits from the use of the flexible backup supplier as an emergency response, but for reasonable purchase premiums and short lead times of flexible backup supply options, their use in a dual (regular and emergency response) role often leads to improved performance over safety lead‐time single and uncertain lead‐time supplier‐replenishment strategies. The benefits of the backup supply options are accentuated the higher the lead‐time uncertainty of the stochastic lead‐time supplier is.     

Managing Safety‐Related Disruptions: Evidence from the U.S. Nuclear Power Industry

Low‐probability, high‐impact events are difficult to manage. Firms may underinvest in risk assessments for low‐probability, high‐impact events because it is not easy to link the direct and indirect benefits of doing so. Scholarly research on the effectiveness of programs aimed at reducing such events faces the same challenge. In this article, we draw on comprehensive industry‐wide data from the U.S. nuclear power industry to explore the impact of conducting probabilistic risk assessment (PRA) on preventing safety‐related disruptions. We examine this using data from over 25,000 monthly event reports across 101 U.S. nuclear reactors from 1985 to 1998. Using Poisson fixed effects models with time trends, we find that the number of safety‐related disruptions reduced between 8% and 27% per month in periods after operators submitted their PRA in response to the Nuclear Regulatory Commission's Generic Letter 88‐20, which required all operators to conduct a PRA. One possible mechanism for this is that the adoption of PRA may have increased learning rates, lowering the rate of recurring events by 42%. We find that operators that completed their PRA before Generic Letter 88‐20 continued to experience safety improvements during 1990–1995. This suggests that revisiting PRA or conducting it again can be beneficial. Our results suggest that even in a highly safety‐conscious industry as nuclear utilities, a more formal approach to quantifying risk has its benefits.     

Introduction to Special Section on Sensitivity Analysis and Summary of NCSU/USDA Workshop on Sensitivity Analysis

This guest editorial is a summary of the NCSU/USDA Workshop on Sensitivity Analysis held June 11–12, 2001 at North Carolina State University and sponsored by the U.S. Department of Agriculture's Office of Risk Assessment and Cost Benefit Analysis. The objective of the workshop was to learn across disciplines in identifying, evaluating, and recommending sensitivity analysis methods and practices for application to food‐safety process risk models. The workshop included presentations regarding the Hazard Assessment and Critical Control Points (HACCP) framework used in food‐safety risk assessment, a survey of sensitivity analysis methods, invited white papers on sensitivity analysis, and invited case studies regarding risk assessment of microbial pathogens in food. Based on the sharing of interdisciplinary information represented by the presentations, the workshop participants, divided into breakout sessions, responded to three trigger questions: What are the key criteria for sensitivity analysis methods applied to food‐safety risk assessment? What sensitivity analysis methods are most promising for application to food safety and risk assessment? and What are the key needs for implementation and demonstration of such methods? The workshop produced agreement regarding key criteria for sensitivity analysis methods and the need to use two or more methods to try to obtain robust insights. Recommendations were made regarding a guideline document to assist practitioners in selecting, applying, interpreting, and reporting the results of sensitivity analysis.     

Does the best practice of rational-style model-based policy analysis already include ethical considerations?,

This paper deals with ethics in the context of the real-world practice of operations research (OR), once an analyst has taken on the responsibility of carrying out a rational-style model-based policy study for a client. OR models are often used by policy analysts to assist decisionmakers in choosing a good course of action based on multiple (and competing) criteria from among a variety of alternatives under uncertain conditions as part of the policy analysis process. The paper suggests that if applied operations researchers (acting as rational-style model-based policy analysts, and not as policy analysts playing a different role or as policy advocates) use the scientific method and apply the generally accepted best practices of their profession, they will be acting in an ethical manner. It, therefore, describes the steps of a typical rational-style model-based policy analysis study, and specifies the tenets of good practice in each step. It also provides a list of questions and statements that the analyst and those evaluating an analyst's work (both internally and externally) can use to help make sure that the study adheres to the tenets of good practice for rational-style model-based policy analysis and remains within ethical bounds.