Procedural violations as a contribution to high-risk accidents Essay
Mason ( 1997 cited in Lawton, 1998, p. 79 ) studies that procedural misdemeanors have been a important contributory factor to 70 % of the entire accidents in bad industries. This is farther illustrated by Walker, et Al. ( 2012 ) where they analysed 108 fatal accidents reported in 2010 and 2011 within oil and gas industry. The survey revealed that unwilled misdemeanors caused 19 % of the human deaths, and knowing misdemeanors caused 15 % of the human deaths.
Researches ( Bowonder, 1987 ; Meshkati, 1991 ; Gupta, 2002 ; Chouhan, 2005 ) show that knowing misdemeanors were a conducive cause of Methyl isocyanate ( MIC ) escape in the Bhopal calamity occurred in 1984. Safety critical equipment such as the infrigidation unit to maintain MIC below 5°C, blowhole gas scrubber designed to neutralize the toxic release and flair tower designed to fire out extra MIC bluess were non working on the twenty-four hours of the incident ; nevertheless, the production was allowed to go on. Furthermore, the probe of the Texas City refinery detonation revealed that the operators and supervisors were allowed to change, edit, add or take procedural stairss without any proficient reappraisals, and procedural divergences were an acceptable pattern within the works ( MacKenzie, et al. , 2007 ; CSB, 2007 ) . These informations and incident findings provide affirmatory grounds that mistakes and misdemeanors related to the disobedience of processs are still a repeating contributory factor in accidents within oil and gas industry.
The probe of Laurence ( 2005 ) on the causes of procedural disobedience in Australian mine workers found that some 19 % of the workers thought that the processs lack existent universe apprehension, 18 % that there are excessively many processs to retrieve, 16 % that the processs are excessively complex, 12 % that the processs are non in a field linguistic communication and 10 % that the processs are hapless in footings of content. The recent research of Dahl, et Al. ( 2013 ) among the employees of Norse offshore service vass were besides statistically proved that the procedural conformity depends on the employees’ apprehension of the content of the processs. The findings of Laurence ( 2005 ) and Dahl, et Al. ( 2013 ) were reinforced by Dahl ( 2013 ) in a survey within the crude oil industry and found that entree to the processs, user-friendliness and preparation have direct influence on the procedural conformity.
These in bend agencies that the root cause of operators’ mistake and misdemeanors related to the procedural conformity are non merely the duty of an employee, but direction besides have an of import function to guarantee that processs are designed with the human capablenesss and restrictions in head.
Research workers have proposed assorted methods to command procedural disobedience. Procedures must qualify the operating bounds and effects that may ensue when diverting from the operating bounds ( Hughes and Kornowa-Weichel, 2004 ) . Management must apportion a capable affair expert to reexamine the processs to guarantee proficient truth and content of the processs before the undertaking executing ( Inaba, et al. , 2004 ) . Levels, system bounds, set points and diagrams to be included in the complex processs to cut down human mistakes. Procedures must qualify the actions to be taken if the parametric quantities are non complied with or out of scope ( Cullan and Anderson, 2005 ) .
An every bit important facet is that it is necessary to affect system end-users in the procedural development to cut down human mistakes. The process design must guarantee that process content, layout and presentation comply with the industry best pattern and can be used and understood by end-users, peculiarly in relation to safety critical operations ( Cullen, 2007 ) .
By the same item, Bates and Holroyd ( 2012 ) stipulate that latest version of the processs must be easy accessible to shop-floor workers. Agreements must besides be in topographic point for regular reappraisal and update in line with the alteration of work procedure and for supervising systems to verify conformity with processs. It is every bit of import that processs must be in a simple linguistic communication that the operator will easy understand ( Cullen and Anderson, 2005 ; Bates and Holroyd, 2012 ) .
- Human factors in preparation and competence direction
Bettering the competence of employee is cardinal to advance safety consciousness and cut down human mistakes. Inadequate preparation frequently consequences in the deficiency of proficient accomplishment and safety consciousness. The organizational factors like failure to set up preparation system and staff ain factors like hapless attitude to developing frequently produce unqualified employees and human mistakes ( Shi Wenwen, et al. , 2011 ) .
To exemplify, the Longford Royal Commission investigated the Esso Longford detonation pointed out that unequal preparation of workers and supervisors was a cause of the accident ( Dawson and Brooks, 1999 ; Barnett, 2006 ; Hopkins, 2000 ) . Additionally, the probe of the British Petroleum ( BP ) Texas City refinery detonation identified that BP failed to guarantee the procedure safety cognition of refinery forces. The over-reliance on BP’s Computer Based Training ( CBT ) caused unequal competence of employees ( Baker, et al. , 2007 ) . It was identified that there were no equal systems in topographic point to pattern managing unnatural state of affairss ( CSB, 2007 ) and for confirmation of the operator cognition and makings ( MacKenzie, et al. , 2007 ) . The findings from these accidents suggest that administrations must hold vigorous competence direction systems in topographic point to forestall human mistakes.
There have been inconclusive arguments about the effectivity of different preparation methods within the bad industries. Burke, et Al. ( 2011 ) in a meta-analysis probe conducted within the excavation industry found that extremely participant prosecuting preparation is well more effectual than less prosecuting preparation when risky exposure badness is high. On the contrary, Brahm and Singer ( 2013 ) did non happen a preparation method superior to any other. On the balance, it is sensible to propose that inactive preparation such as CBT must non replace more piquant schoolroom and practical preparation Sessionss within the bad industries. Such determinations must be based on cost-benefit analysis to forestall similar competence issues identified in the BP Texas City accident.
Several human factors surveies have appeared in recent old ages documenting the preparation issues. Hughes and Kornowa-Weichel ( 2004 ) insisted the importance of keeping the competence of trainers. Records must maintain of what has been covered in the preparation and what advancement has been made to maintain the path of employees’ competence.
Scholars besides suggest that preparation should include a scope of normal and exigency operation scenarios, and should concentrate on safety critical undertakings, and for which there may be spreads in competence ; peculiarly, for undertakings that are infrequently performed and new undertakings introduced ( Cullen, 2007 ; Cullen and Anderson 2005 ) . Ganguly ( 2011 ) indicates that direction should guarantee so much of information are non given to employees in less clip that will be hard to absorb, and employee may non understand to the full about the new occupation. Administrations should besides guarantee that each critical safety processs are supported with preparation to guarantee employees’ conformity ( Bates and Holroyd ; 2012 ) . Smithers ( 2010 ) and Ganguly ( 2011 ) stipulate that systems must be in topographic point for continued and refresher preparation and post-training rating to keep and better the competency of employees to forestall human mistakes.
- Human factors in hazard appraisal
The safety and unity of any procedure works are dependent on the quality of the design. It is non surprising so that proficient design factors and design failures dominate the Process Hazard Analysis ( PHA ) ensuing in less accent on human-related issues ( Kariuki and Lowe, 2007 ) .
The survey of Skogdalen and Vinnem ( 2011 ) is an effort to turn to this issue of how the Human and Organisation Factors ( HOFs ) are included and reflected in the Quantitative Risk Assessment ( QRA ) within the Norse Shelf and UK. Skogdalen and Vinnem ( 2011 ) reviewed 15 QRAs for different installings collected from five runing companies. It has been found that five QRAs were covered the proficient and operational hazard decrease factors and no attending were given to HOFs, eight QRAs explained the importance of HOFs to some extent ; nevertheless, the influence of the assessment theoretical account and computations on the system merely explained to a limited extend, two QRAs analysed the HOFs in a structured manner utilizing a criterion method which identified the causes of mistakes and controls and theoretical accounts were adjusted harmonizing to the findings, and none of the QRAs considered HOFs are merely every bit of import as proficient 1s. This seems to formalize the position of Kariuki and Lowe ( 2007 ) that less accent is given to human related issues compared to the design factors in the procedure jeopardy analysis surveies.
This is farther illustrated in the probe of BP Texas City refinery detonation that the safety direction system of BP failed to guarantee equal designation, hazard appraisal, tracking and rectification of procedure safety jeopardies ( Baker, et al. , 2007 ) .
During the past decennary, the integrating of HOFs into the failure chance and hazard appraisal has been loosely researched. The research of Oien ( 2001 ) , Cacciabue ( 2004b ) , Aven, et Al. ( 2006a, 2006b ) , Vinnem, et Al. ( 2008 ) and Noroozi, et Al. ( 2013 ) show a assortment of attacks such as Organizational Risk Influence Model ( ORIM ) , Human Error Risk Management for Engineering Systems ( HERMES ) , Barrier and Operational Risk Analysis ( BORA ) , Operational Control Safety ( OTS ) and Success Likelihood Index Method ( SLIM ) for the effectual execution of HOFs to put on the line appraisal.
The cardinal point to observe is that the nucleus of each method is the consideration and appraisal of organizational and human factors such as processs and preparation, occupation design, human-machine interface, undertaking environment, workplace design and operator features ; hence, administrations should look for the most appropriate tool that tantrum or congratulate their bing hazard direction attacks.