High-hazard Industries Research Articles

A Mini Review (PRISMA) on Causes of Incidents and Injuries Occurring in Agricultural Workplaces

Agriculture, alongside construction and mining, is one of the three most hazardous industries, and is characterized by numerous risk factors for occupational accidents. Unlike other industries, agriculture faces significant safety concerns related to the natural environment. Determining the causes of accidents is therefore imperative for accident prevention. However, the difficulty in investigating accidents owing to inadequate reporting and management systems among self-employed farmers hampers the determination of their causes. This study aims to determine the factors influencing agricultural accidents through a literature review. A systematic literature search was conducted according to the PRISMA guidelines. The initial search yielded 165 articles of which 34 papers were selected after removing those by applying the selection criteria. The selected papers were categorized into three domains: work accidents, machinery accidents, and farmer safety promotion. Accident causes were classified using the 4M technique: machine, media, man, and management. The results were visualized with a heat map. The main causes of accidents thus identified were insufficient operation/management, inappropriate work situation, and insufficient education/training. The findings of this study can serve as foundational data for developing measures to improve working environments not only in agriculture but also in other high-hazard industries.

Cognitive technology development and end-user involvement in the Norwegian petroleum industry – Human factors missing or not?

The petroleum industry is a high-hazard industry depending on reliable technical solutions. The industry tends to use increasingly advanced technologies including machine learning technology with increased difficulties for end users to keep abreast of how these technologies work. Thus, our research question was: How are end users involved in the development and implementation of cognitive technologies in the Norwegian petroleum industry to contribute to safe and reliable technical solutions? We used a qualitative explorative approach, with semistructured interviews with 31 informants from 10 companies. Thematic analysis revealed the categories ‘technology focus’, ‘understanding of end-user involvement versus end users’ actual involvement’, ‘lack of access to end users’, ‘lack of human factors methods in early phases’, and ‘lack of official rules and regulations’. Findings show that during the earlier phases of designing algorithms and training data, end users are hardly involved. Regarding later phases with offshore testing, implementation, use, and improvement, end users are much more integrated in the process.

Assessment of emergency risk management and resilience engineering at management levels of a high hazard industry

The current study aimed to, firstly, assess the roles of crisis management systems, resilience engineering, and proactive risk management in emergency management of high-risk manufacturing industry and, secondly, to compute the relative contribution of each factor by the entropy approach. Data were collected using three questionnaires. The Technique for Order Preference by Similarity to Ideal Solution (TOPSIS) was administered to rank study alternatives, which include managers at different hierarchical levels encompassing senior managers, middle‐level managers, and operating-level managers. The results of the entropy method considering crisis management data suggested that human and organisational aspects had the highest impact on emergency management. The highest percentages of influence considering resilience engineering factors were associated with flexibility and management commitment to safety. Among proactive risk management dimensions, training and communication about safety and risks were the most influential dimensions. TOPSIS results demonstrated that there are some gaps in the emergency management system of the plant from the operating managers’ perspectives. This means that operating managers believed that the emergency management system and resilience level should be improved in the plant to enhance the levels of safety and emergency risk management of the industry.

The Relationship Between Stress and Sleep Sufficiency in the Context of Varied Workplace Social Support.

Sufficient sleep is essential for well-being. We examined the relationship between work-related social support, work stress, and sleep sufficiency, predicting that workers with higher social support would report higher sleep sufficiency across varying levels of work stress. The data set analyzed in the present study included 2213 workers from approximately 200 small (<500 employees) businesses in high, medium, and low hazard industries across Colorado. Perceived social support variables moderated the relationship between work stress and sleep sufficiency such that employees reporting higher levels of social support reported higher sleep sufficiency when work stress was low or moderate but not high. Although preventing work stress is optimal, in cases where employers cannot apply primary interventions to prevent stress (eg, eliminating/reducing night shifts), employers should attempt to increase social support or other more relevant resources for employees.

Shift Work and Sleep Disturbance in the Oil Industry.

Rotating shift work is common in high-hazard industries, despite documented associations with sleep disturbance and impairment. In the oil industry, where rotating and extended shift schedules are used to staff safety-sensitive positions, work intensification and increasing overtime rates have been broadly documented over the last few decades. Research on the impacts of these work schedules on sleep and health has been limited for this workforce. We examined sleep duration and quality among rotating shift workers in the oil industry and explored associations between schedule characteristics, sleep, and health outcomes. We recruited hourly refinery workers from the West and Gulf Coast oil sector members of the United Steelworkers union. Impaired sleep quality and short sleep durations were common and associated with health and mental health outcomes common among shift workers. Shortest sleep durations followed shift rotations. Early rise and start times were associated with shorter sleep duration and poorer sleep quality. Drowsiness and fatigue-related incidents were common. We observed lower sleep duration and quality and increased overtime in 12-hour rotating shift schedules. These long workdays with early start times may reduce available hours for quality sleep; here they were associated with reduced exercise and leisure activity which correlated with good sleep. This safety-sensitive population appears severely impacted by poor sleep quality, which has broader implications for process safety management. Later start times, slower rotation, and a reconsideration of two-shift schedules are interventions to consider for improving sleep quality among rotating shift workers.

Complexity and Risk Management in High-Hazard Industry: Evidence from Oil and Gas Transportation in the United States

고위험산업에서 복잡성의 중요성은 널리 알려져 있는 반면, 원유와 가스 운송업에서 복잡성에 대한 실증 연구는 부족한 실정이다. 이에 본 연구는 복잡성이 원유와 가스 운송 사고비용에 미치는 영향을 실증적으로 살펴보았다. 본 연구는 미국 파이프라인 및 위험물질 안전청으로부터 720개의 파이프라인 운영사 자료를 수집하였다. 14년에 걸친 2,743 파이프라인 운영사-연도 자료를 바탕으로 통제변수와 고정효과를 고려한 음이항회귀모형을 이용하여 복잡성의 효과를 분석하였다. 실증분석 결과 복잡성과 단위길이당 사고비용은 유의한 양(+)의 관계를 갖는 것으로 나타났다. 특히, 파이프라인 보호와 관련한 복잡성과 달리 파이프라인의 직경이나 연령과 관련한 복잡성이 사고비용과 유의한 관계를 보이는 것으로 나타났다. 본 연구는 어떠한 유형의 복잡성이 원유와 가스 운송업 위험관리에서 중요한지 밝힘으로써 고위험산업 관련 문헌에 공헌하고 파이프라인 운영사와 규제기관에 시사점을 제공하고 있다.

How Risk-Informed Decisions Can Fail: Lessons from a Nuclear Power Plant Incident

In 2002, a large hole was discovered in the reactor vessel head of the Davis-Besse plant located in Ohio, US. Had the reactor pressure vessel ruptured, a major public safety event would have occurred. Further investigations revealed that, by the end of 2001, a shutdown order was drafted by the Regulatory Agency. Nonetheless, through a risk-informed decision-making approach, the Agency changed the decision related to the issuance of the order. Operations were then allowed to continue for six more weeks, despite the high likelihood that the reactor was operating with leaking cracks in the nozzles located at the reactor head. The reactor vessel head wastage, which had evolved unnoticed for years, was primarily due to borated water that leaked through a nozzle crack onto the carbon steel portion of the reactor head, resulting in boric acid corrosion. This paper aims to explore the Agency’s decision-making to identify factors that might have contributed to the flawed decision. A better comprehension on the organizational factors and social processes that can adversely affect risk-informed decisions is crucial to enhance operational safety in high hazard industries. The paper concludes by suggesting possible ways to guard against the identified factors.

Fatality risk management: Applying Quinlan’s Ten Pathways in Western Australia’s mining industry

In ‘Ten Pathways to Death and Disaster’ Professor Michael Quinlan (2014) identified a series of ten common catastrophic incident risk factors, known as the Ten Pathways, contributing to major incidents in mining and other high hazard industries. This study applies the Quinlan methodology in two separate phases. The first phase of the study explored employee perception of employer effectiveness of fatality prevention against each of the Ten Pathways through a questionnaire of n = 2009 participants at the 2017–2019 Western Australian Government Mines Safety Roadshows. Respondents generally perceived their employer as having a relatively good understanding of the role of risk assessments and their importance in preventing injuries yet perceived their employers as generally ineffective in management system auditing. In the second phase of the study, 71 fatality reports on the Western Australian Government Department of Mines Fatalities register were assessed to identify the Ten Pathways involved in the fatality. The analysis identified fatalities typically included four or five of the Ten Pathways, although none of the investigations analysed all Ten Pathways. A combined assessment of employee perceptions of employer’s effectiveness at fatality prevention and pathways present in the Mines Fatalities register identified which Quinlan Ten Pathways mining organisations should prioritise for fatality prevention. It is recommended that benchmarking safety performance, incident investigations, and reviews of effectiveness of safety management systems include an examination and verification of the organisation’s response to Ten Pathways, a relatively straight forward task which may highlight latent issues or weaknesses that may otherwise remain undetected.

Don’t sweat the small stuff? Superstitious Organizational Learning from Experience with Near Misses

A near-miss is an event where the possibility of a failure is present but does not materialize. Many organizations in high-hazard industries have recently adopted near-miss learning systems in the hope that their members will learn from such events to prevent significant failures from occurring in the future. The challenge with correctly learning from near misses is that since the event is not a failure, decision makers must recognize that although a negative event did not happen, it might have occurred. If decision makers do not correctly distinguish between successes and near-misses, organizations and their members can systematically take away the wrong lessons from the event and future performance could decline (rather than improve) as experience accumulates. This negative learning pattern, referred to as “superstitious learning,” has been identified in other contexts, but has not been explored in connection to near misses. In addition to exploring the role of near-misses in superstitious learning, we also explore what signals for learning are provided from heterogeneous versus homogenous near-miss experiences. We use data from reportable safety incidents in the US coal mining industry and a behavioral study set in the context of a coal mining decision to test our hypotheses.

Exploring oil and gas industry workers’ knowledge and information needs

Many incident reports and much research literature have concluded that incident rates in high-hazard industries can be reduced by enhancing the knowledge and information sources available to workers. However, a sparsity of published research reporting workers' perspectives on the value of information and knowledge sources in different operational situations potentially limits the effectiveness of interventions aimed at improving human responses to process safety performance. In response, this work seeks to understand how frontline oil and gas industry workers, responsible for managing process safety and other risks in their hazardous workplaces, rely on their own knowledge, the knowledge of others and information provided to manage different operating scenarios. A set of open and closed-ended survey questions were distributed to workers at several upstream and downstream oil and gas companies. Statistical analysis of 133 responses revealed interesting insights relating to participants’ experience levels, decision making practices and perceptions on the importance of various information and knowledge sources in different operating circumstances. The data revealed differences in the sources of knowledge relied upon by experienced and less experienced workers. Experienced workers rely on their own knowledge in both routine and potentially high-impact scenarios. Less experienced workers also rely on their own knowledge for routine decisions however they reported seeking out external knowledge and information in potentially high-impact scenarios. The data suggests that interventions to improve safety by enhancing the availability of knowledge and information sources are less likely to affect experienced workers and alternate strategies might be needed. However, such interventions might be effective if they are focused on supporting newer workers.

Shifted Firefighter Health Investigation by Personal Health Insurance Record in Taiwan.

IntroductionTaiwan’s firefighters use a shift rotation system with 2 days of work and 1 day of rest. Numerous papers have already explored the risks of shift work to the body. However, little data concern the impact of shift work on health as reflected in medical visits. This study used individuals’ medical visit record in Taiwan’s health insurance system. The locally called “health bank” contains individuals’ medical visit record, health insurance payment points and the medicine used.MethodsConsent was obtained from 150 firefighters who were serving under the shift rotation system to obtain their 2015 individual “My Health Bank” medical data. Comparisons were made between national health insurance data norm.ResultsFirefighters make significantly more visits for Western medicine than the annual average (firefighters 6.27 vs norm 5.24, P = 0.04142), more total number of medical visits (9.57 vs 7.75, P = 0.0102), more annual average payment points for Western medicine (4079 vs 2741, P = 0.003151), and a greater average number of total annual medical visit points (7003 vs 4940, p = 0.0003157). Firefighters had significantly higher incidents of respiratory diseases, urogenital diseases, skin and subcutaneous tissue diseases, musculoskeletal system and connective tissue diseases, injuries, and illness from poisoning than did the norm (P<0.05).ConclusionA persuasive health-survey-based method for workers in high occupational hazard industries was proposed in this study, and the result was highly correlated with risk factors of fireworkers. The proposed study method is potential to investigate risk factors of other working.

Testing Alertness of Emergency Physicians: A Novel Quantitative Measure of Alertness and Implications for Worker and Patient Care

Establishing practical solutions to manage fatigue in health care settings could reduce errors. Predictive Safety SRP Inc.'s AlertMeter is a 2-min cognitive assessment tool currently used in high-hazard industries to identify fatigued staff. No prior study has attempted to address fatigue in emergency medicine (EM). We objectively assessed provider alertness to determine potential application of software-based fatigue recognition for risk reduction. In a double-blind, prospective evaluation from July 1 to September 30, 2016, we applied the AlertMeter to EM residents at an academic level I trauma center. The tool was applied before and after shifts to evaluate alertness in three types of shifts: day, evening, and night. All residents were invited to participate-27 of 30 enrolled. Analysis of covariance (ANCOVA) was implemented to examine shift and completion effects on alertness score using baseline score as a covariate. Additionally, three separate ANCOVAs were conducted to examine alertness score differences between portion (start vs. end) and type of shift (day, evening, or night). Residents were significantly less alert at the completion of the evening shift. Scores at the end of the night shift were significantly lower than the start of the night shift. Alertness software can be reliably integrated into the emergency department. Alertness was lower at the end of the evening shift and end of the night shift. This work could have positive implications on shift and task scheduling and potentially reduce errors in patient care by quantifying providers' fatigue and identifying areas for countermeasures.

Analysis and Estimation of Human Errors From Major Accident Investigation Reports

Abstract Risk analyses require proper consideration and quantification of the interaction between humans, organization, and technology in high-hazard industries. Quantitative human reliability analysis approaches require the estimation of human error probabilities (HEPs), often obtained from human performance data on different tasks in specific contexts (also known as performance shaping factors (PSFs)). Data on human errors are often collected from simulated scenarios, near-misses report systems, and experts with operational knowledge. However, these techniques usually miss the realistic context where human errors occur. The present research proposes a realistic and innovative approach for estimating HEPs using data from major accident investigation reports. The approach is based on Bayesian Networks used to model the relationship between performance shaping factors and human errors. The proposed methodology allows minimizing the expert judgment of HEPs, by using a strategy that is able to accommodate the possibility of having no information to represent some conditional dependencies within some variables. Therefore, the approach increases the transparency about the uncertainties of the human error probability estimations. The approach also allows identifying the most influential performance shaping factors, supporting assessors to recommend improvements or extra controls in risk assessments. Formal verification and validation processes are also presented.

Modifications to the Decision Ladder to match frontline workers’ critical decision making

The Decision Ladder (DL) Template is often used to understand workers’ reasoning processes. In high-hazard industries such as oil refining, frontline workers’ decisions are crucial to managing abnormal situations and preventing unwanted events. This paper describes research undertaken–using the DL Template–to analyze workers’ responses to abnormal situations as elicited during Critical Decision Method interviews. The paper firstly describes the evolution DL Template since Rasmussen’s original writings. It then describes challenges encountered when using the traditional DL Template to analyze interview responses. A modified DL Template is proposed that provides a more detailed top portion of the template to allow more explicit analysis of how knowledge-based reasoning might be used when addressing abnormal, safety-critical situations.

Achieving World Class Performance in Oil and Gas Industry Using Inherently Safer Design

Hazard Identification, consequence evaluation, risk mitigation analysis, and management of effective safeguards are key to effective risk (safety) management. The high hazard industry, in its quest to achieve safer operations, has developed several risk assessment techniques that prescribe the addition of safeguards, usually safety systems, as the primary means to mitigate risk. This has led to complexity and not necessarily safer plants as evidenced by a trail of major process safety incidents.High profile incidents with associated asset losses, increased public concern on safety issues and changes to regulatory expectations have driven the industry to consider inherently safer design (ISD) options. Chevron, on its journey to achieve world class operations, has adopted and deployed ISD principles during the execution of major capital projects (MCPs). As early as the alternatives generation stage of a MCP, projects rigorously evaluate options that allow for simpler and robust facility design.This paper is based on the systematic application of ISD principles in offshore MCPs. The paper share examples of how ISD was applied in early MCP engineering phases and the benefits of the structured ISD application.

Opportunities to enhance barrier management through incident analysis

Many high hazard industries use bowties to analyze and assess risks. In the bowtie risk analysis model, barriers are identified which aim to prevent, control or mitigate unwanted scenarios.However, despite best effort risks assessments, incidents and near misses may still occur. When they do, organizations typically conduct investigations to come up with recommendations to avoid similar situations in the future. Unfortunately, in many cases these investigation reports end up as a collection of largely unstructured documents. They are often treated as single events, making it difficult to clearly identify trends over multiple events.Scenario-based Incident Registration (SIR) aims to provide a more structured process. A user selects a specific scenario from a set of bowties and assesses the effectiveness of the barriers identified on the original bowtie. Specific questions are asked per barrier about the reasons of the failure. These findings are stored on a barrier level. If this process is repeated, the bowtie will accumulate barrier failure data of multiple incidents in a single diagram. This information helps the organization to identify the strength of their barriers, which in turn facilitates risk-based decision-making.Some incidents require in-depth investigations and a registration only is not enough. However, this registration can be used as a starting point for the incident analysis. Doing barrier-based incident analysis allows you to learn from barrier failures and improve their performances in order to prevent similar incidents from happening. This incident data together with the SIR data can be linked back to the bowtie diagram in order to spot the strengths and weaknesses of your visual risk assessment.SIR is a continuous process which is more than a reporting system. The reporter does not require knowledge about the bowtie methodology, while incident managers receive valuable insight to their pro-active risk assessment.

A minimization algorithm for automata generated fault trees with priority gates

Fault tree analysis is still widely practiced in high-hazard industries. We propose in this article an algorithm for the reduction of fault tree expressions that are generated from automata representations of failure behaviors. Automata formalisms are increasingly being used to describe systems exhibiting sequence-dependent failures—i.e., the overall outcome like a total failure of the system can depend on the order in which events occur. A set of paths leading to a safety-relevant state is encoded as a standard sum of product canonical form, and without any loss of the significance of the sequencing of events. That is, the corresponding fault tree expression is basically a Boolean formula which is extended with the necessary temporal features (event occurrence priority). Such expressions can then be reduced into minimal canonical forms by using the Boolean methods together with the required temporal logic calculus. Since minimal failure sequences can be determined from the obtained reduced models, the proposed approach can improve the analysis of the dynamic effects of the sequencing of faults and propagated errors in such models. As a consequence, it can have a positive impact on the design of failure prevention measures. A fault tolerant example system exhibiting dynamic behavior is used to highlight the benefits of the approach.

The role of risk avoidance and locus of control in workers’ near miss experiences: Implications for improving safety management systems

The process industry has made major advancements and is a leader in near-miss safety management, with several validated models and databases to track close call reports. However, organizational efforts to develop safe work procedures and rules do not guarantee that employees will behaviorally comply with them. Assuming that at some point, every safety management system will need to be examined and realigned to help prevent incidents on the job, it is important to understand how personality traits can impact workers' risk-based decisions. Such work has been done in the mining industry due to its characteristically high risks and the results can be gleaned to help the process industry realign goals and values with their workforce. In the current study, researchers cross-sectionally surveyed 1,334 miners from 20 mine sites across the United States, varying in size and commodity. The survey sought to understand how mineworkers' risk avoidance could impact their near miss incidents on the job – a common precursor to lost-time incidents. Multiple regressions showed that as a miner's level of risk avoidance increased by 1 unit in the 6-point response scale, the probability of experiencing a near miss significantly decreased by 30% when adjusting for relevant control variables. Additionally, a significant interaction between risk avoidance and locus of control suggested that the effect of risk avoidance on near misses is enhanced as a miner's locus of control increases. A one-unit increase in locus of control appends the base effect of risk avoidance on near misses with an additional 8% decrease in the probability. Findings are discussed from a near-miss safety management system perspective in terms of methods to foster both risk avoidance and locus of control in an effort to reduce the probability of near misses and lost time at the organizational level within the process industry and other high-hazard industries.

Analyzing the heterogeneity of labor and delivery units: A quantitative analysis of space and design.

This study assessed labor and delivery (L&D) unit space and design, and also considered correlations between physical space measurements and clinical outcomes. Design and human factors research has increased standardization in high-hazard industries, but is not fully utilized in medicine. Emergency department and intensive care unit space has been studied, but optimal L&D unit design is undefined. In this prospective, observational study, a multidisciplinary team assessed physical characteristics of ten L&D units. Design measurements were analyzed with California Maternal Quality Care Collaborative (CMQCC) data from 34,161 deliveries at these hospitals. The hospitals ranged in delivery volumes (<1000–>5000 annual deliveries) and cesarean section rates (19.6%-39.7%). Within and among units there was significant heterogeneity in labor room (LR) and operating room (OR) size, count, and number of configurations. There was significant homogeneity of room equipment. Delivery volumes correlated with unit size, room counts, and cesarean delivery rates. Relative risk of cesarean section was modestly increased when certain variables were above average (delivery volume, unit size, LR count, OR count, OR configuration count, LR to OR distance, unit utilization) or below average (LR size, OR size, LR configuration count). Existing variation suggests a gold standard design has yet to be adopted for L&D. A design-centered approach identified opportunities for standardization: 1) L&D unit size and 2) room counts based on current or projected delivery volume, and 3) LR and OR size and equipment. When combined with further human factors research, these guidelines could help design the L&D unit of the future.

A Safety Culture Maturity Matrix for Nuclear Regulatory Bodies

The concept of safety culture has attracted a great deal of attention. Since the rise of the concept, progress has been made regarding the definition of safety culture and the development of tools dedicated to safety culture oversight and self-assessment. In addition, these recent advances have been made across different high-hazard industries, and obviously in the nuclear world. Nevertheless, little attention has been paid to tailored methods allowing a regulatory body to assess its own safety culture. The aim of this paper is to present a framework adapted to nuclear regulatory bodies or TSOs (Technical Safety Organisations) in order to guide them in understanding their own safety culture through a “Safety Culture Maturity Matrix”.