Accidents, often the result of an ‘uncontrolled business process’—a study in the (Dutch) chemical industry

Sonnemans, Pjm Peter; Körvers, P.M.W.; Brombacher, AC Aarnout; Beek, PC van; Reinders, J.

doi:10.1002/qre.527

Cited by 7 publications

(3 citation statements)

References 8 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…4.2.3 Double-loop learning. In addition to acknowledging discrepancies and contradictions in learning from incidents, some authors propose approaches aimed at bring about much desired but difficult to achieve double-loop learning (Sonnemans et al, 2003). Sonnemans for example examines root-cause analysis models as a form of double-loop process where existing, non-existing and inefficient norms are questioned (2008).…”

Section: What Kind Of Learning Process Is Adopted?mentioning

confidence: 99%

How organisations learn from safety incidents: a multifaceted problem

Lukic

Margaryan

Littlejohn

2010

Journal of Workplace Learning

View full text Add to dashboard Cite

Purpose -This paper seeks to review current approaches to learning from health and safety incidents in the workplace. The aim of the paper is to identify the diversity of approaches and analyse them in terms of learning aspects. Design/methodology/approach -A literature review was conducted searching for terms incident/accident/near misses/disaster/crisis modified with learning/training and safety. Shortlisted articles were analysed by questioning who is learning, what kind of learning process is undertaken, what type of knowledge is employed and the type of problem that these incidents addressed. Current approaches to learning from incidents were critically analysed and gaps identified.Findings -Very few papers addressed all the envisaged aspects when developing their learning from incidents approaches. With support from literature, it was concluded that all the four perspectives, namely participants of learning (participation and inclusion), learning process (single loop, double learning), type of incident and its relation to learning (Cynefin complexity framework) and types of knowledge (conceptual, procedural, dispositional and locative) are important when deciding on an appropriate learning from incidents approach.Research limitations/implications -The literature review focused on journal articles and identified keywords, which might have narrowed the scope. Further research is needed in identifying ways to embed the learning from incidents aspects in the organisation. Practical implications -The framework developed could be useful by safety planners, safety managers, human resource managers and researchers in the area of organisational learning and safety. Originality/value -The paper concludes by outlining key questions and proposing a framework that could be useful in systematically analysing and indentifying effective approaches to learning from incidents.

show abstract

Section: What Kind Of Learning Process Is Adopted?mentioning

confidence: 99%

How organisations learn from safety incidents: a multifaceted problem

Lukic

Margaryan

Littlejohn

2010

Journal of Workplace Learning

View full text Add to dashboard Cite

show abstract

“…For example, Chung and Jefferson (1998) have developed an approach to integrate accident databases with computer tools used by chemical plant designers, operators, and maintenance engineers, permitting accident reports to be easily accessed and analyzed. In addition, Sonnemans, Korvers, Brombacher, van Beek, and Reinders (2003) have investigated 17 accidents that have occurred in the Netherlands petrochemical industries and have demonstrated qualitatively that had accident precursor information been recorded, with proper measures to control future occurrences, these accidents could have been foreseen and possibly prevented. Furthermore, Sonnemans and Korvers (2006) observed that even after recognizing accident precursors and disruptions, the operating systems inside companies often fail to prevent accidents.…”

Section: A Meel Et Al / Journal Of Loss Prevention In the Process Imentioning

confidence: 99%

Operational risk assessment of chemical industries by exploiting accident databases

Meel

O'Neill

Levin

et al. 2007

Journal of Loss Prevention in the Process Industries

102

View full text Add to dashboard Cite

Accident databases (NRC, RMP, and others) contain records of incidents (e.g., releases and spills) that have occurred in the USA chemical plants during recent years. For various chemical industries, [Kleindorfer, P. R., Belke, J. C., Elliott, M. R., Lee, K., Lowe, R. A., & Feldman, H. I. (2003). Accident epidemiology and the US chemical industry: Accident history and worst-case data from RMP*Info. Risk Analysis, 23(5), 865-881.] summarize the accident frequencies and severities in the RMP*Info database. Also, [Anand, S., Keren, N., Tretter, M. J., Wang, Y., O'Connor, T. M., & Mannan, M. S. (2006). Harnessing data mining to explore incident databases, the Journal of Hazardous Material, 130,[33][34][35][36][37][38][39][40][41] use data mining to analyze the NRC database for Harris County, Texas.Classical statistical approaches are ineffective for low frequency, high consequence events because of their rarity. Given this information limitation, this paper uses Bayesian theory to forecast incident frequencies, their relevant causes, equipment involved, and their consequences, in specific chemical plants. Systematic analyses of the databases also help to avoid future accidents, thereby reducing the risk.More specifically, this paper presents dynamic analyses of incidents in the NRC database. The NRC database is exploited to model the rate of occurrence of incidents in various chemical and petrochemical companies using Bayesian theory. Probability density distributions are formulated for their causes (e.g., equipment failures, operator errors, etc.), and associated equipment items utilized within a particular industry. Bayesian techniques provide posterior estimates of the cause and equipment-failure probabilities. Cross-validation techniques are used for checking the modeling, validation, and prediction accuracies. Differences in the plantand chemical-specific predictions with the overall predictions are demonstrated. Furthermore, extreme value theory is used for consequence modeling of rare events by formulating distributions for events over a threshold value. Finally, the fast-Fourier transform is used to estimate the capital at risk within an industry utilizing the frequency and loss-severity distributions. Classical statistical approaches are ineffective for low frequency, high consequence events because of their rarity. Given this information limitation, this paper uses Bayesian theory to forecast incident frequencies, their relevant causes, equipment involved, and their consequences, in specific chemical plants. Systematic analyses of the databases also help to avoid future accidents, thereby reducing the risk.More specifically, this paper presents dynamic analyses of incidents in the NRC database. The NRC database is exploited to model the rate of occurrence of incidents in various chemical and petrochemical companies using Bayesian theory. Probability density distributions are formulated for their causes (e.g., equipment failures, operator errors, etc.), and associated equipment items utilized wit...

show abstract

“…Researchers have successfully integrated human factors components in accident investigation tools [1] or have developed an elaborate model in which organisational and technical elements are coupled together [2,3]. These approaches are useful for either the organisation that wishes to learn more from accidents or for researchers who are studying connections between two separate worlds of scientific subjects.…”

mentioning

confidence: 99%

Choosing between organisational & technical safety: a practical approach for industry

Gort

Reinders

Zwanikken

2004

Probabilistic Safety Assessment and Management

View full text Add to dashboard Cite

For several years it has been tried to make a connection between organisational and technical safety. Researchers have successfully integrated human factors components in accident investigation tools [1] or have developed an elaborate model in which organisational and technical elements are coupled together [2,3]. These approaches are useful for either the organisation that wishes to learn more from accidents or for researchers who are studying connections between two separate worlds of scientific subjects. Management of industries however likes to know firstly its actual safety performance and secondly in what area of safety money should be spent [4,5]. Neither of the tools mentioned is sufficiently equipped to give these answers. TNO has combined a technical risk assessment with an organisational safety assessment. The result is the use of a combination of instruments, techniques and methods that enforce each other and give a company good insight in what the state of safety management is. The outcomes of the different surveys lead to a solid comparison of technological and organisational measures to be taken and serve as a basis for further decision making. The method is tested in a pilot study in a chemical production site. This paper describes the developed methods for organisational safety and the use of it by the case company.

show abstract

Accidents, often the result of an ‘uncontrolled business process’—a study in the (Dutch) chemical industry

Cited by 7 publications

References 8 publications

How organisations learn from safety incidents: a multifaceted problem

How organisations learn from safety incidents: a multifaceted problem

Operational risk assessment of chemical industries by exploiting accident databases

Choosing between organisational & technical safety: a practical approach for industry

Contact Info

Product

Resources

About