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Prevention of Accidents Through Experience Feedback

ISBN-10: 0748409254

ISBN-13: 9780748409259

Edition: 2000

Authors: Urban Kjellen

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Description:

Tis study provides information on how to reduce accidents in the workplace. It introduces the various methods and tools of SHE practice, including methods of accidents and near-accident reporting and investigation.
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Book details

Copyright year: 2000
Publisher: CRC Press LLC
Publication date: 7/20/2000
Binding: Hardcover
Pages: 424
Size: 6.50" wide x 9.50" long x 1.25" tall
Weight: 2.134
Language: English

List of figures
List of tables
Preface
Acknowledgements
Introduction
Introducing the concept of SHE information systems
Model of a SHE information system
Human information-processing analogy
What does research tell us about the effects of SHE information systems?
Developing the model further
Boundary conditions
Conditions inside the company
Size, type of technology and resources
The organisational context
The outer context
The employer's responsibilities
Regulations on record keeping and on the reporting of injuries and incidents to the authorities
Workers' compensation systems
International standards and guidelines
Other non-governmental organisations
Alternative accident-prevention approaches
Barriers against hazards
Administrative system for feedback control
Arenas for organisational learning
Risk homeostasis
Case study: Reducing emissions to the air from a fertiliser plant
Theoretical foundation
Accident models
On the need for accident models
Causal-sequence models
Process models
Energy model
Logical tree models
Human information-processing models
Moving the perspective to the organisational context
SHE management models
The SHE culture
Framework for accident analysis
Characteristics of the accident sequence
Consequences of accidents
Types of consequences
Consequence measures
Economic consequences of accidents
Actual versus potential losses
Incident (uncontrolled energy flow)
Deviations
Heinrich's classical man-environment taxonomy
Ergonomics and industrial-engineering systems views
Contributing factors and root causes
Contributing factors at the functional department and work-system levels
Root causes at the general and SHE-management-systems levels
Problems in identifying causal factors
Accident counter-measures
Barriers against losses
Prevention of occupational accidents
Prevention of major accidents due to fires and explosions
Active and passive barriers
Different time frames in the implementation and maintenance of barriers
The role of experience transfer
Designing for safety of machinery
Safety measures in operation
The permit-to-work system
The human element in accident control
Human information processing
Human errors
Definition
Human-error taxonomies
Error recovery
The influence of emotion
Preventing human errors and promoting error recovery
The role of the operators in major-accident prevention
Unscheduled manual interventions
Fallacy of the defences-in-depth philosophy
High-reliability organisations
The occurrence of accidents over time
Feedback and use of experiences in decision-making
Overview of feedback mechanisms
Uses of SHE-related information in decision-making
The diagnostic process
Effects of limitations in human information-processing capacity
Hale's problem-solving cycle
Deming's circle
Persistent feedback control
Ashby's law of requisite variety
Van Court Hare's hierarchy of order of feedback
Obstacles to an efficient learning from experience
Organisational defences
Local information and the SHE information system
Culpability and liability
A balanced approach
Requirements for a SHE information system
Requirements for SHE performance indicators
Requirements for the SHE information system as a whole
Data collection
Distribution and presentation of information
The SHE information system as a whole
Learning from incidents and deviations
Sources of data on accident risks
The ideal scope of different data-collection methods
Filters and barriers in data collection
Accident and near-accident reporting and investigation
Why report and investigate accidents and near accidents?
Investigations at three levels
Reporting
Reporting to the authorities
Problems of under-reporting
Near-accident reporting
Immediate investigation and follow-up
Quality of the supervisor's first report
Use of checklists and reporting forms
Displaying the sequence of events
Computer-supported accident investigations
Registration of accident costs
Group problem-solving
In-depth accident and near-accident investigations
The steps in an in-depth investigation
Applying SMORT in in-depth investigations
Legal aspects of the commission's report
Computer-supported distribution of the investigation report
A procedure for accident and near-accident reporting and investigation
SHE inspections and audits
Inspections
Workplace inspections
Inspecting and testing barrier integrity
SHE audits
Application of SMORT in audits
Accumulated accident experience
Database on accidents and near accidents
Database definition
Accessing the database
Coding of accident and near-accident data
Analysis of accident and near-accident data
Finding accident repeaters
Uni- and bi-variate distribution analyses
Accident-concentration analysis
Analysis of accident causes
Severity-distribution analysis
Extreme-value projection
Experience carriers
Monitoring of SHE performance
Overview of SHE performance indicators
Loss-based SHE performance indicators
The lost-time injury frequency rate
The control chart
The problems of SHE performance measurement
Zero-goal mindset
Other loss-based SHE performance indicators
Measures of risk
Standard loss-based SHE performance indicators
Untraditional SHE performance indicators
Process-based SHE performance indicators
SHE performance indicators based on near-accident reporting
Behavioural sampling
Causal factor-based SHE performance indicators
Rating the elements of a company's SHE management system
International Safety Rating System (ISRS)
Self-rating as a means of improving SHE management
Tripod Delta
Measurement of safety climate
Measuring the degree of learning from incidents
Selecting key SHE performance indicators
Combinations of SHE performance indicators
Indicators of barrier availability
Risk analysis
The risk-analysis process
What is risk analysis?
Acceptance criteria for the risk of losses due to accidents
Methods of risk analysis
Coarse or energy analysis
Planning
Execution and documentation
Identification of hazards and causes
Risk estimation
Development of safety measures
Documentation and follow-up of results
Establishing a database on potential accidents
Detailed job-safety analysis
Analysis object
Resource needs and scheduling
Description of the steps of the job
Subsequent steps
Accidental exposure to chemicals
Systematic mapping of hazards within an organisation
Risk assessments of machinery
Requirements as to risk assessments
Method for risk assessment
Determination of the limits of the machinery (Step 1)
Coarse risk assessment (Step 2)
Detailed risk assessment of the machinery (Step 3)
Comparison risk analysis
Acceptance criteria for the risk of occupational accidents
Risk-assessment model
Assumptions
The steps of the analysis
Criop
Putting the pieces together
The oil and gas industry
Accidents in offshore oil and gas production
The Ymer Platform
Design
Organisation and manning
Prevention of accidents in design
The phase model for offshore field exploration and development
SHE management principles
Prevention of major accidents
Prevention of occupational accidents
Construction-site safety
SHE management principles
Step 1: Pre-qualification
Step 2: Tender evaluation and clarification, contract award
Step 3: Evaluation of the SHE programmes
Step 4: Follow-up during construction
Safety during plant operation
SHE management principles
Policy and goals
Implementation
Control and verification
The trucking industry
Accidents in road transportation
Measures of the risk of traffic accidents
The man-vehicle-road-environment model
The driver
The vehicle
The traffic environment
Sources of information on traffic-accident risks
Feedback mechanisms
The trucking company
The truck manufacturer
The roads administration
Improving the corporate SHE information system
The improvement process
Evaluation of existing conditions
Establishing goals and defining user needs
Developing solutions and following up results
Design of the system
Database definition
Organisation and routines
Personnel
Instruments and tools
Epilogue
Definitions
SMORT questionnaire
Bibliography
Name index
Subject index