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Otsikko Lihavoituna Accident cases TU-E3150 Safety management in complex sociotechnical systems Teemu Reiman 22.3.2020 2 TU-E3150 Safety management in complex sociotechnical systems Tentative agenda and topics of the lectures 1. 27.2. Introduction and the basic concepts of safety management 2. 5.3 Basic concepts: From human to organizational factors 3. 12.3 Accident models and organizational accidents 4. 19.3 Accident cases ▪ Mid-term assignment 5. 26.3 Organizational learning 6. 2.4 Safety culture ▪ Returning the mid-term assignment (before 16.4) 7. 16.4 Safety leadership 8. 23.4. The basic principles of safety management 9. 30.4. Tools of safety management I 10.7.5. Tools of safety management II 11.14.5 Future challenges of safety management 12.20.5 Presentation of the final papers ▪ Deadline for returning the paper 29.5.2020 22.3.2020 3 Potential topics for the final paper The idea of the final paper is that you select a concrete topic of interest and analyze that topic with the models and theories introduced in this course: ▪ Safety management tool / method (e.g. “Application of AcciMap method”) ▪ Accident case (e.g. Three Mile Island, Estonia) ▪ Good practice, or successful case / company (e.g. “safety management at company x” ▪ Location, context, country (e.g. “safety culture in Malta”, “Safety management in nuclear industry) You can also select the theoretical concept first and then apply it to a selected case, e.g. ▪ Human error approaches (e.g. “human errors in manufacturing industry”) ▪ Different accident models (e.g. “Three Mile Island accident in light of epidemiological and systems accident models”) ▪ Safety culture models and theories (e.g. “safety culture in construction industry“) ▪ Cultural (national, organizational, occupational) influences on safety ▪ A systems approach to safety ▪ Safety leadership ▪ Learning from errors / incidents ▪ However, whatever the selected theory / concept, remember to consider it critically, based on the “adaptive age” of safety management 22.3.2020 4 TU-E3150 Safety management in complex sociotechnical systems ▪ Seminar paper ▪ 10-15 pages on a selected topic (font 12, line spacing 1,5) ▪ Separate writing instructions will be published on the course website => these need to be followed ▪ Deadline for returning the paper 29.5.2020 22.3.2020 5 Mid-term assignment ▪ Read the paper “Space Shuttle Challenger Explosion” ▪ Answer the following questions (2-6 pages total): 1) In your opinion, what were the most significant reasons and contributing factors of the explosion of Space Shuttle Challenger? 2) In your opinion, what was the major missed opportunity to prevent the disastrous chain of events? Why was it missed? 3) What information you felt was missing from the paper that would have helped you to better understand the causes of the accident? On what topic you would have wanted more information as an accident investigator? 4) What is the relevance of the accident of the 80s for the present day safety management? Deliver the paper by email ([email protected]) before 16.4. The paper is not graded but its quality affects the overall course grading The paper can be written in English or Finnish 22.3.2020 6 Open system models Normal, ‘born’ Organizational models HOW ACCIDENTS HAPPEN: : normal variability in HOW ACCIDENTS HAPPEN : Organizations gradually some parts or elements of the system resonate with drift and develop routines, normalize and simplify their variability with other parts causing a stochastic event. environment until some previously recognized or Unexpected combinations create hazards. completely new hazard actualizes. HOW TO PREVENT THEM: understanding how people HOW TO PREVENT THEM: understanding how the and organizations normally function, supporting daily organization functions, and the gap between formal and trade-offs, recognizing sources of variability and informal organization, making the boundaries of safe potential combinations that create hazards activity visible, monitoring the changes in the boundary HAZARDS: combination of existing hazards and new HAZARDS: combination of existing latent hazards and gradual emergent situation specific hazards new slowly emerging system hazards sudden Linear models Epidemiological (closed systems) models HOW ACCIDENTS HAPPEN : slow build-up of resident HOW ACCIDENTS HAPPEN : A chain of events initiated pathogens (latent errors) in the system and its barriers by a mistake or failure and that leads to actualization (during so called incubation period) followed by an of an existing hazard initiating event (active error) HOW TO PREVENT THEM: recruitment of safe people, HOW TO PREVENT THEM: removing pathogens or making attitude training, technical barriers (inserting barriers, sure they do not activate by e.g. safety barriers (tech & org), removing non-functioning elements), one hazards at a fixing small failures before they propagate into disaster. time, System is safe when it employes safe people. System is safe when it that has no holes in its defenses. HAZARDS physical and technical hazards that HAZARDS: physical and technical hazards that activate due to faulty human action. Can be failures in human and organizational activity set free. recognized by hazard analyses (FMEA, HAZOP), and Can be identified by organizational risk analyses (e.g. incident reporting. MORT, fault trees), and operating experience systems. Abnormal, ‘caused’ 6 22.3.2020 7 Common contributing factors to organizational accidents Leadership Coping with changes Management Unders- system tanding Culture (basic assumptions) 22.3.2020 8 Common contributing factors to organizational accidents 1 LEADERSHIP ▪ An insufficient understanding of ‘operational reality’ by leaders (‘good news’ culture and a failure to encourage constructive challenge, inattention to weak signals) [IAEA 2016] ▪ Lack of deference to expertise when making decisions ▪ Lack of open upward communication ▪ Reliance on simplistic or misleading indicators ▪ Production pressures and short term efficiency focus ▪ Power plays ▪ Blaming attitude and lack of systems thinking ▪ Lack of employee involvement in safety improvement 22.3.2020 9 Common contributing factors to organizational accidents 2 WORK PROCESSES and the MANAGEMENT SYSTEM ▪ Insufficient communication and coordination between departments / organizations ▪ Structural secrecy / risk information concealment ▪ Complexity of the organization / unclear roles and responsibilities ▪ Inadequate oversight and supervision, including contractors ▪ Lack of technical inquisitiveness ▪ Reactive approach to development / lack of training & seeking new information ▪ A failure to learn from previous events [at own organization or external] ▪ Lack of effective corrective actions program ▪ Informal practices and lack of adherence to the management system 22.3.2020 10 Common contributing factors to organizational accidents 3 KNOWLEDGE AND UNDERSTANDING ▪ Deficiencies in technical competence ▪ Inadequate understanding of the current condition of the plant ▪ Insufficient understanding of safety issues in decision making and actions ▪ Inadequate understanding of human and organizational issues related to safety ▪ Usability issues, wellbeing and motivation, fatigue etc. ▪ Inadequate knowledge of how the own organization or stakeholders behave 22.3.2020 11 Common contributing factors to organizational accidents 4 COPING WITH CHANGES ▪ Normalization (acceptance) of abnormal conditions or deviations; ▪ Unintended consequences of organizational or technical changes ▪ Gradual drift in local practices ▪ Changing the design during construction / modifying the design for new purpose when the system is in use 22.3.2020 12 Common characteristics of major accidents ▪ They rarely have a single cause, a single clear mishap or malfunction as a source ▪ On the other hand, ordinary mistakes can do extraordinary damage in complex technological systems ▪ Typically adverse conditions develop over time, during so called incubation period ▪ During this period there are weak signals that if spotted and investigated could prevent the accident ▪ Typically these weak signals are neglected due to either normalizing them, or considering them in isolation as non-significant ▪ Thus, most accidents are unexpected but not sudden ▪ Accidents are rarely caused by a single exceptional event but rather they are a consequence of an unexpected combination of several ordinary events 22.3.2020 14 A simplified accident model illustrating how incidents are born out of a combination of latent conditions, active variability and errors and various concurrent events. Technology Safety management: development of processes and technology, identification and control of latent conditions, setting and maintenance of safety barriers, anticipating dangerous events and combinations, corrective actions Barriers Latent conditions Organizational Technical safety systems, redundancies, PPEs, automatic shutdowns, emergency services processes LEADERSHIP Workload, poor motivation, climate Technical breakdowns due to WORK PROCESSES, latent conditions MANAGEMENT SYSTEM Organizational Unclear responsibilities & organizing of work, deficient SITUATIONS AND COMBINATIONS structures information flow, non-adherence Rare tasks, new tasks, new workers, special to the management system situations Several simultaneous errors, unexpected couplings Non-wanted Conse- KNOWLEDGE and & combinations, complex situations, delayed and event quences UNDERSTANDING non-linear effects Unawareness of hazards, gaps in Personnel competence External UNNOTICED
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