An analysis of CSB investigation reports concerning the hierarchy of controls

Amyotte, Paul; MacDonald, Dustin K.; Khan, Faisal

doi:10.1002/prs.10461

Cited by 25 publications

(11 citation statements)

References 10 publications

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“…That said, the proportion of non‐administrative risk controls recommended in this study was also much higher than the ∼20% found in a systematic review of risk control after root cause analysis in healthcare and echoed by a similar study in the field of occupational health and safety . Additionally, anecdotal evidence suggests that run‐of‐the‐mill RCAs and PRAs may result in far lower percentages of non‐administrative controls than an assessment of published RCAs might suggest.…”

Section: The Pilot Study: Discussionmentioning

confidence: 81%

Rebalancing risk management—Part 2: The Active Risk Control (ARC) Toolkit

Card

Ward

Clarkson

2015

J of Healthc Risk Manag

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The adoption of systems-focused risk assessment techniques has not led to measurable improvement in the rate of patient harm. Why? In part, because these tools focus solely on understanding problems and provide no direct support for designing and managing solutions (ie, risk control). This second installment of a 2-part series on rebalancing risk management describes a structured approach to bridging this gap: The Active Risk Control (ARC) Toolkit. A pilot study is presented to show how the ARC Toolkit can improve the quality of risk management practice.

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Section: The Pilot Study: Discussionmentioning

confidence: 81%

Rebalancing risk management—Part 2: The Active Risk Control (ARC) Toolkit

Card

Ward

Clarkson

2015

J of Healthc Risk Manag

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“…We first classified events based on their potential consequences. Researchers have recognized the need to focus on events that have high consequences, yet may occur relatively infrequently, because such events can result in serious injury or fatality to one or more employees, and can cost the organization financially with significant property damage (the low‐probability/high‐consequence approach) . However, it is complex and challenging to model low‐probability/high‐consequence events .…”

Section: Methodsmentioning

confidence: 99%

“…Researchers have recognized the need to focus on events that have high consequences, yet may occur relatively infrequently, because such events can result in serious injury or fatality to one or more employees, and can cost the organization financially with significant property damage (the low-probability/high-consequence approach). (31)(32)(33)(34)(35)(36)(37) However, it is complex and challenging to model low-probability/high-consequence events. (26) It may be more important to consider the consequences of events from an incident-mitigation perspective.…”

Section: Evaluation Frameworkmentioning

confidence: 99%

Failing to Fix What is Found: Risk Accommodation in the Oil and Gas Industry

Stackhouse

Stewart²

2016

Risk Analysis

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The present program of research synthesizes the findings from three studies in line with two goals. First, the present research explores how the oil and gas industry is performing at risk mitigation in terms of finding and fixing errors when they occur. Second, the present research explores what factors in the work environment relate to a risk-accommodating environment. Study 1 presents a descriptive evaluation of high-consequence incidents at 34 oil and gas companies over a 12-month period (N = 873), especially in terms of those companies' effectiveness at investigating and fixing errors. The analysis found that most investigations were fair in terms of quality (mean = 75.50%), with a smaller proportion that were weak (mean = 11.40%) or strong (mean = 13.24%). Furthermore, most companies took at least one corrective action for high-consequence incidents, but few of these corrective actions were confirmed as having been completed (mean = 13.77%). In fact, most corrective actions were secondary interim administrative controls (e.g., having a safety meeting) rather than fair or strong controls (e.g., training, engineering elimination). Study 2a found that several environmental factors explain the 56.41% variance in safety, including management's disengagement from safety concerns, finding and fixing errors, safety management system effectiveness, training, employee safety, procedures, and a production-over-safety culture. Qualitative results from Study 2b suggest that a compliance-based culture of adhering to liability concerns, out-group blame, and a production-over-safety orientation may all impede safety effectiveness.

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“…The same research team (led by Paul Amyotte and Faisal Khan) previously reviewed 60 CSB reports that had been published over the period of 1998-2010 using the framework described in the previous section. The results were presented at the 13th Process Plant Safety Symposium [2] and subsequently published in the journal Process Safety Progress [3]. The research described in Amyotte et al [2,3] is hereafter referred to as the previous analysis to distinguish it from the current work (termed the current analysis) and the combined view of the previous and current analyses (termed the overall analysis).…”

Section: Previous Analysismentioning

confidence: 99%

“…Following this introduction, the analysis results from our previous review of 60 CSB reports [2,3] are briefly recapitulated. The authors then present the results and key findings of our current analysis of 25 different CSB reports , followed by an overview of the 85 total reports combined.…”

Section: Introductionmentioning

confidence: 99%

Chemical safety board investigation reports and the hierarchy of controls: Round 2

Amyotte

Irvine

Khan

2018

Process Safety Progress

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Twenty‐five reports of the US Chemical Safety Board over the period December 2009–May 2016 were analyzed for evidence of examples related to inherent safety, passive, and active engineered safety, and procedural safety. These measures were also analyzed for their contribution to incident prevention and consequence mitigation, as well as their applicability to specific elements of the PSM system recommended by the Canadian Society for Chemical Engineering. This work represents the continuation of a previous study that performed a similar analysis for 60 CSB reports written during the period 1998–2010. The update provided here further illustrates the significant value of CSB investigation reports in demonstrating lessons learned and in training and educational efforts. Procedural safety was identified as the most common risk control measure cited in CSB reports, while the efficacy of inherent safety principles in incident prevention and mitigation has been consistently recognized by the CSB in its investigations. Risk reduction efforts aimed at incident prevention were found to be cited more often than those aimed at consequence mitigation. Active engineered safety measures were determined to be common among mitigation efforts due to the prevalence in the process industries of emergency alarms and fire suppression systems. © 2018 American Institute of Chemical Engineers Process Saf Prog 37: 459–466, 2018

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An analysis of CSB investigation reports concerning the hierarchy of controls

Cited by 25 publications

References 10 publications

Rebalancing risk management—Part 2: The Active Risk Control (ARC) Toolkit

Rebalancing risk management—Part 2: The Active Risk Control (ARC) Toolkit

Failing to Fix What is Found: Risk Accommodation in the Oil and Gas Industry

Chemical safety board investigation reports and the hierarchy of controls: Round 2

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