B Enhancing Safety: The Challenge of Foresight ESReDA Project Group Foresight in Safety EUR 30441 EN Page 1 of 252 This publication is final Technical report from ESReDA Project Group “Foresight in Safety” published by the Joint Research Centre (JRC), the European Commission’s science and knowledge service. It aims to provide evidence-based scientific support to the European policymaking process. The scientific output expressed does not imply a policy position of the European Commission. Neither the European Commission nor any person acting on behalf of the Commission is responsible for the use that might be made of this publication. EU Science Hub https://ec.europa.eu/jrc JRC122252 EUR 30441 EN PDF ISBN 978-92-76-25189-7 ISSN 1831-9424 doi:10.2760/814452 KJ-NA-30441-EN-N Print ISBN 978-92-76-25188-0 ISSN 1018-5593 doi:10.2760/382517 KJ-NA-30441-EN-C Luxembourg: Publications Office of the European Union, 2020 © European Union, 2020 The reuse policy of European Commission documents is implemented based on Commission Decision 2011/833/EU of 12 December 2011 on the reuse of Commission documents (OJ L 330, 14.12.2011, p. 39). Except otherwise noted, the reuse of this document is authorised under a Creative Commons Attribution 4.0 International (CC-BY 4.0) licence (https://creativecom mons.org/ licenses/by/4.0/). This means that reuse is allowed provided appropriate credit is given and any changes are indicated. All content © as noted in the report chapters, except cover photo: Christopher Liang, Binoculars “Enhancing Safety: The Challenge of Foresight” 2009. Source: www.flickr.com/photos/chrisliang82/3169050348. (CC BY 2.0). Edited by ESReDA Project Group Foresight in Safety How to cite this report: ESReDA Project Group Foresight in Safety, Enhancing Safety: The Challenge Available from: ESReDA website: www.esreda.org, of Foresight, EUR 30441 EN, Publications Office of the European Union, Luxembourg, 2020, ISBN 978-92-76-25189-7, doi:10.2760/814452, JRC122252. Joint Research Centre https://publications.jrc.ec.europa.eu/repository and https://op.europa.eu/en/web/general-publications/publications Page 2 of 252 Preface by ESReDA President thanks are due to those organisations that have allowed working group members to participate in this work including giving free access to their extensive in-house expertise and experience. We record our appreciation and grateful thanks to: Foresight in safety is a critical capability for high-risk industries. It is needed to achieve sustainable, reliable and safe performance: failures of foresight have been • Agenția de Investigare Feroviară Română (AGIFER), Romania observed in most accidents. Foresight in safety requires a mindset within operating • Collectif Heuristique pour l’Analyse Organisationnelle de Sécurité (CHAOS), companies and regulators to think ahead and to remain critical about current risks France that are not fully controlled or acceptable, and to develop vigilance to new threats. • Électricité de France, EDF R&D, France; We should humbly acknowledge that risk anticipation is a difficult challenge and • Energias de Portugal (EDP) – Gestão da Produção de Energia, S.A., Portugal; has no perfect, simple or definitive solution in complex systems. Indeed, systems • European Commission, DG-Joint Research Centre, Energy, Transport & are dynamic, continuously evolving with important changes, such as the current Climate, (JRC), the Netherlands; and DG-Joint Research Centre, Space, massive digitalisation, and external challenges - some with potential major crisis Security & Migration, (JRC), Italy consequences such as the COVID19 pandemic that surprised many stakeholders. • Federal Public Service Employment, Labour and Social Dialogue, Belgium • Fondation pour une Culture de Sécurité Industrielle (FonCSI), France The European Safety, Reliability and Data Association (ESReDA) was created almost • Institut de Radioprotection et de Sûreté Nucléaire (IRSN), France; thirty years ago to help stakeholders to cope with these kinds of challenges. Its • Kindunos Safety Consultancy Ltd, the Netherlands; principle is cooperative: across boarders in Europe; as well as between industries, • Noordwijk Risk Initiative Foundation (NRI Foundation), The Netherlands, institutions, and authorities. ESReDA is a non-profit making association of • European industrial and academic organisations that promotes advances in the Societatea Nationala Nuclearelectrica SA, Romania, • fields of safety and reliability. ESReDA is a forum for experts to exchange potential SRL Health, Safety, and Environment Consulting, Norway strategies and solutions to cope with these kinds of challenges. The association • Starline, USA always welcomes comments and contributions concerning their publications and • Tukes - Safety Technology Authority, Finland; invites all to submit ideas for further developments in the field of new safety • University of Pardubicze, Czech Republic measures and reliability data as well. In addition, we specifically thank the Joint Research Centre of the European The analyses and proposals presented here were written by an ESReDA project Commission for their support on the publication and dissemination of this ESReDA group. This report would not have been possible without substantial individual deliverable. We hope this report meets the expectations of members of the public efforts by the ESReDA project group members who come from different and organisations who have shown interest in the work of the group in this companies, research institutes, universities and authorities. They have produced important field. its contents without any financial support and have devoted considerable free time to the task. This publication is based on extensive experience from several industrial sectors (transportation, energy, chemical…) and countries in Europe. ESReDA is proud to present the results of their work and hopes it will benefit the Porto, November 2020 Saclay, November 2020 many organisations and individuals worldwide concerned with foresight in safety Luis Andrade Ferreira Mohamed Eid challenges. Universidade do Porto CEA ESReDA would like to thank the authors for their contribution and also the member Former President of ESReDA Current President of ESReDA organisations for funding travel expenses for its members. In particular special Page 3 of 252 Preface by the ESReDA Project Group Foresight in Safety Chapter 6 points out that visualisation of early warning signs is critical to a clear understanding of the causes of existing weaknesses and to defining proper actions to prevent their escalation; This report is the result of a joint effort by experts, working in the fields of risk 1 management, accident analysis, learning from experience and safety Chapter 7 shows how the ESReDA Cube can be used to identify foresight potential management. They come from 10 countries, mainly from Europe but also from the for detection of Early Warning Signs; USA and Australia. Their expertise covers several industrial sectors. Chapter 8 focuses on the investigation and diagnosis of dysfunctional The report aims to provide useful information, from both theoretical and practical organisational factors, in particular those than may lead to a safety level decrease viewpoints, about “Foresight in Safety”, based on current practices and the state with potential negative consequences; of scientific knowledge. Chapter 9 identifies areas of the asset management process that can be used to Safety is an area concerned by ongoing debate (e.g. is goal of safety to ensure that generate safety foresight, enabling the detection of process and 'as few things as possible go wrong' or to ensure that ‘as many things as possible systems/equipment deterioration and other anomalies before a serious accident go right’?), but we can assume that safety implies continued correct operation of can occur; the process such that errors and failures do not lead to major accidents. Chapter 10 explains how analysis of “big data” can help to detect Early Warning The contents of this publication are summarised below. Signs of system failure, and can predict occurrence of very infrequent events affecting safety; Chapter 11 focuses on the role of whistleblowers and argues that taking advantage Chapter 1 presents the case for a new approach to “foresight in safety”, based in of information provided by these persons could help avoid the occurrence of particular on the literature in future studies, and presents its theories, traditions, events; and challenges; Chapter 12 presents technologies, domains and applications that can be used to Chapter 2 shows how foresight is conceptually located between system resilience improve safety directly and by enabling use of foresight; and listening to whistleblowers; Chapter 13 describes some daily activities of regulators and discusses the ways in Chapter 3 aims to characterise some of the failures to foresee major accidents in which regulators can generate and disseminate foresight during these activities. order to foster the ongoing debate about the best strategies to enhance “foresight in safety”; Chapter 4 claims that organisational loss of memory is a topic to be taken into This report can be read either as a whole (by downloading the full report) or you account, in particular the loss of knowledge regarding Early Warning Signs; can read only single chapters (a hyperlink is available for every chapter on the ESReDA dedicated webpage – www.esreda.org). Chapter 5 demonstrates that scenarios describing potential event sequences