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(PDF) Identifying the Underlying System-Based Causes of Human Errors in Major Chemical Incidents | Bill Hoyle - Academia.edu

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{"work":{"id":83361649,"created_at":"2022-07-18T08:04:56.787-07:00","from_world_paper_id":210823019,"updated_at":"2023-11-12T20:16:01.692-08:00","_data":{"publication_date":"1999,,"},"document_type":"paper","pre_hit_view_count_baseline":null,"quality":"high","language":"en","title":"Identifying the Underlying System-Based Causes of Human Errors in Major Chemical Incidents","broadcastable":true,"draft":null,"has_indexable_attachment":true,"indexable":true}}["work"]; window.loswp.workCoauthors = [104446511]; window.loswp.locale = "en"; window.loswp.countryCode = "SG"; window.loswp.cwvAbTestBucket = ""; window.loswp.designVariant = "ds_vanilla"; window.loswp.fullPageMobileSutdModalVariant = "control"; window.loswp.useOptimizedScribd4genScript = false; window.loswp.appleClientId = 'edu.academia.applesignon';</script><script defer="" src="https://accounts.google.com/gsi/client"></script><div class="ds-loswp-container"><div class="ds-work-card--grid-container"><div 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PDF</p></div><div class="ds-work-cover--ribbon-container">Download Free PDF</div><div class="ds-work-cover--ribbon-triangle"></div></button></div></div></div><div class="ds-work-card--work-information"><h1 class="ds-work-card--work-title">Identifying the Underlying System-Based Causes of Human Errors in Major Chemical Incidents</h1><div class="ds-work-card--work-authors ds-work-card--detail"><a class="ds-work-card--author js-wsj-grid-card-author ds2-5-body-md ds2-5-body-link" data-author-id="104446511" href="https://independent.academia.edu/BillHoyle1"><img alt="Profile image of Bill Hoyle" class="ds-work-card--author-avatar" src="https://0.academia-photos.com/104446511/25919149/24572651/s65_bill.hoyle.jpg" />Bill Hoyle</a></div><p class="ds-work-card--detail ds2-5-body-sm">1999</p><div class="ds-work-card--button-container"><button class="ds2-5-button js-swp-download-button" 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data-landing_url="https://www.academia.edu/83361649/Identifying_the_Underlying_System_Based_Causes_of_Human_Errors_in_Major_Chemical_Incidents" data-login_uri="https://www.academia.edu/registrations/google_one_tap" data-moment_callback="onGoogleOneTapEvent" id="g_id_onload"></div><div class="ds-top-related-works--grid-container"><div class="ds-related-content--container ds-top-related-works--container"><h2 class="ds-related-content--heading">Related papers</h2><div class="ds-related-work--container js-wsj-grid-card" data-collection-position="0" data-entity-id="88454385" data-sort-order="default"><a class="ds-related-work--title js-wsj-grid-card-title ds2-5-body-md ds2-5-body-link" href="https://www.academia.edu/88454385/Learning_from_language_problem_related_accident_information_in_the_process_industry_A_literature_study">Learning from language problem related accident information in the process industry: A literature study</a><div class="ds-related-work--metadata"><a 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Implicated in this are language proficiency and literacy, but also readability of instructions. Coupled to these is the fact that the global workforce holds more migrant workers than ever before, and there are a growing number of multi-lingual shop floor environments, especially in the transportation and health care sectors. The term ‘language problem related accident’ (LPRA) is proposed here. This article reviews LPRA trends in industry, especially in the process industry and construction industry. Proposals are made about how to better manage the safety risks associated with LPRAs. LPRA information was gathered via a literature survey using search-terms related to LPRAs. This search included the governmental resources in Europe, the USA, Australia, several Far East countries, and Africa. Both the information found and the difficulties encountered while gathering this information were analysed and validated by interviews with experts. Causal information about LPRAs is partial at best: 21 access difficulties are identified. Their resolution will create opportunities for further safety improvement. The main proposals made here relate to public information systems, company safety management, regulatory inspections, accident investigation activities and safety science research.</p><div class="ds-related-work--ctas"><button class="ds2-5-text-link ds2-5-text-link--inline js-swp-download-button" data-signup-modal="{&quot;location&quot;:&quot;wsj-grid-card-download-pdf-modal&quot;,&quot;work_title&quot;:&quot;Learning from language problem related accident information in the process industry: A literature study&quot;,&quot;attachmentId&quot;:92574337,&quot;attachmentType&quot;:&quot;pdf&quot;,&quot;work_url&quot;:&quot;https://www.academia.edu/88454385/Learning_from_language_problem_related_accident_information_in_the_process_industry_A_literature_study&quot;,&quot;alternativeTracking&quot;:true}"><span class="material-symbols-outlined" style="font-size: 18px" translate="no">download</span><span class="ds2-5-text-link__content">Download free PDF</span></button><a class="ds2-5-text-link 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It collects and summarizes experiences from the oil and gas industry in Latin America and the World in the last ten years (2011-2021). However, those experiences could be extrapolated and applied to other industries. The study will systematically show the ten common mistakes to be avoided during the process of investigation. Those common mistakes are closely related to failures in the understanding of incidents and associated problems, dealing with incomplete information and relevant data, misinterpretation of data and information gathered in incident scenarios, no identification of critical root causes, inefficient use of incident analysis techniques, and generation of reports which not address suitable solutions to avoid re-occurrence of events. Finally, the study describes some recommendations and practical tips to avoid common mistakes and identify them before they emerge during the investigation process.</p><div class="ds-related-work--ctas"><button class="ds2-5-text-link ds2-5-text-link--inline js-swp-download-button" data-signup-modal="{&quot;location&quot;:&quot;wsj-grid-card-download-pdf-modal&quot;,&quot;work_title&quot;:&quot;Common mistakes when conducting Incident Investigations in Process Safety&quot;,&quot;attachmentId&quot;:74871891,&quot;attachmentType&quot;:&quot;pdf&quot;,&quot;work_url&quot;:&quot;https://www.academia.edu/61981697/Common_mistakes_when_conducting_Incident_Investigations_in_Process_Safety&quot;,&quot;alternativeTracking&quot;:true}"><span class="material-symbols-outlined" style="font-size: 18px" translate="no">download</span><span class="ds2-5-text-link__content">Download free PDF</span></button><a class="ds2-5-text-link ds2-5-text-link--inline js-wsj-grid-card-view-pdf" href="https://www.academia.edu/61981697/Common_mistakes_when_conducting_Incident_Investigations_in_Process_Safety"><span class="ds2-5-text-link__content">View PDF</span><span class="material-symbols-outlined" style="font-size: 18px" translate="no">chevron_right</span></a></div></div><div class="ds-related-work--container js-wsj-grid-card" data-collection-position="5" data-entity-id="18520300" data-sort-order="default"><a class="ds-related-work--title js-wsj-grid-card-title ds2-5-body-md ds2-5-body-link" href="https://www.academia.edu/18520300/Language_issues_an_underestimated_safety_risk">Language issues, an underestimated safety risk</a><div class="ds-related-work--metadata"><a class="js-wsj-grid-card-author ds2-5-body-sm ds2-5-body-link" data-author-id="38555712" href="https://independent.academia.edu/Lindhout">Paul Lindhout</a></div><p class="ds-related-work--metadata ds2-5-body-xs">Loss Prevention Bulletin</p><p class="ds-related-work--abstract ds2-5-body-sm">After observation of increased major incident rates in 2002 and 2003 several government investigations showed that language and culture were not well recorded factors in causality. Safety culture was explored in 2006. In 2009 poor safety procedures were found to be the biggest causal factor of investigated major incidents in the Netherlands. Related safety documents appeared in some cases to be technically correct but had not been understood nor accurately followed. This initiated a study at the Delft Technical University - TBM Safety Science Group to further investigate language and safety. Language issues turn out to be an underestimated danger. 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Continuous improvement on accident knowledge and understanding is vital for process safety. Thus, an initiative to study the latest trends of accident was taken by analyzing 75 completed investigation reports of US Chemical Safety and Hazard Investigation Board (CSB) accident cases occurred in CPI from 1995 to 2011. The result of the analysis shows that the CPI accepted the concept of Prevention trough Design (PtD). However, 71% of accident cases are similar due to incorrect corrective action taken.</p><div class="ds-related-work--ctas"><button class="ds2-5-text-link ds2-5-text-link--inline js-swp-download-button" data-signup-modal="{&quot;location&quot;:&quot;wsj-grid-card-download-pdf-modal&quot;,&quot;work_title&quot;:&quot;An Analysis of Major Accident in the Us Chemical Safety Board (CSB) Database&quot;,&quot;attachmentId&quot;:68334579,&quot;attachmentType&quot;:&quot;pdf&quot;,&quot;work_url&quot;:&quot;https://www.academia.edu/50294520/An_Analysis_of_Major_Accident_in_the_Us_Chemical_Safety_Board_CSB_Database&quot;,&quot;alternativeTracking&quot;:true}"><span class="material-symbols-outlined" style="font-size: 18px" translate="no">download</span><span class="ds2-5-text-link__content">Download free PDF</span></button><a class="ds2-5-text-link ds2-5-text-link--inline js-wsj-grid-card-view-pdf" href="https://www.academia.edu/50294520/An_Analysis_of_Major_Accident_in_the_Us_Chemical_Safety_Board_CSB_Database"><span class="ds2-5-text-link__content">View PDF</span><span class="material-symbols-outlined" style="font-size: 18px" translate="no">chevron_right</span></a></div></div><div class="ds-related-work--container js-wsj-grid-card" data-collection-position="7" data-entity-id="11921951" data-sort-order="default"><a class="ds-related-work--title js-wsj-grid-card-title ds2-5-body-md ds2-5-body-link" href="https://www.academia.edu/11921951/IMPLEMENTATION_OF_A_SAFETY_PROGRAM_FOR_THE_WORK_ACCIDENTS_CONTROL_A_CASE_STUDY_IN_THE_CHEMICAL_INDUSTRY">IMPLEMENTATION OF A SAFETY PROGRAM FOR THE WORK ACCIDENTS’ CONTROL. A CASE STUDY IN THE CHEMICAL INDUSTRY</a><div class="ds-related-work--metadata"><a class="js-wsj-grid-card-author ds2-5-body-sm ds2-5-body-link" data-author-id="29518788" href="https://fiocruz.academia.edu/DepartamentoDeSegurancaMeioAmbienteESaudeLuizAlexandreMoscaCunha">Departamento De Seguranca Meio Ambiente E Saude Luiz Alexandre Mosca Cunha</a></div><div class="ds-related-work--ctas"><button class="ds2-5-text-link ds2-5-text-link--inline js-swp-download-button" data-signup-modal="{&quot;location&quot;:&quot;wsj-grid-card-download-pdf-modal&quot;,&quot;work_title&quot;:&quot;IMPLEMENTATION OF A SAFETY PROGRAM FOR THE WORK ACCIDENTS’ CONTROL. A CASE STUDY IN THE CHEMICAL INDUSTRY&quot;,&quot;attachmentId&quot;:37289718,&quot;attachmentType&quot;:&quot;pdf&quot;,&quot;work_url&quot;:&quot;https://www.academia.edu/11921951/IMPLEMENTATION_OF_A_SAFETY_PROGRAM_FOR_THE_WORK_ACCIDENTS_CONTROL_A_CASE_STUDY_IN_THE_CHEMICAL_INDUSTRY&quot;,&quot;alternativeTracking&quot;:true}"><span class="material-symbols-outlined" style="font-size: 18px" translate="no">download</span><span class="ds2-5-text-link__content">Download free PDF</span></button><a class="ds2-5-text-link ds2-5-text-link--inline js-wsj-grid-card-view-pdf" href="https://www.academia.edu/11921951/IMPLEMENTATION_OF_A_SAFETY_PROGRAM_FOR_THE_WORK_ACCIDENTS_CONTROL_A_CASE_STUDY_IN_THE_CHEMICAL_INDUSTRY"><span class="ds2-5-text-link__content">View PDF</span><span class="material-symbols-outlined" style="font-size: 18px" translate="no">chevron_right</span></a></div></div><div class="ds-related-work--container js-wsj-grid-card" data-collection-position="8" data-entity-id="39263350" data-sort-order="default"><a class="ds-related-work--title js-wsj-grid-card-title ds2-5-body-md ds2-5-body-link" href="https://www.academia.edu/39263350/Demything_human_error_by_re_analyzing_incidents_in_a_heavy_machinery_manufacturer">Demything &quot;human error&quot; by re-analyzing incidents in a heavy machinery manufacturer</a><div class="ds-related-work--metadata"><a class="js-wsj-grid-card-author ds2-5-body-sm ds2-5-body-link" data-author-id="34151889" href="https://independent.academia.edu/MarceloCostella">Marcelo Costella</a></div><p class="ds-related-work--abstract ds2-5-body-sm">This paper presents the results of a study on the incidents that happened in a heavy machinery manufacturer in Brazil during the 2004 year. Incidents were analyzed based on i) the information available in the registration form of the safety and health department; ii) re-analysis by reconstruction of the incident. From all 125 incidents recorded by the enterprise in 2004, 36 could be fully analyzed according to the classification proposed by Reason (1990, 1997, 1998) and Rasmussen&amp;#39;s (1997) SRK framework. Although 50% of the incidents were considered to be due to human error, re-analysis showed that 42% of the 36 cases were slips (SBB type errors), 11% were KBB type errors (they happened in new/unpredictable situations), 11% were worker&amp;#39;s violation of a rule (RBB type errors) and 6% were other worker&amp;#39;s violation. In 45% of the slips, the root cause was improper use of tools and equipments. Bad layout was the root cause of 20% of the slips. KBB errors have, in 67% of the ca...</p><div class="ds-related-work--ctas"><button class="ds2-5-text-link ds2-5-text-link--inline js-swp-download-button" data-signup-modal="{&quot;location&quot;:&quot;wsj-grid-card-download-pdf-modal&quot;,&quot;work_title&quot;:&quot;Demything \&quot;human error\&quot; by re-analyzing incidents in a heavy machinery manufacturer&quot;,&quot;attachmentId&quot;:59397484,&quot;attachmentType&quot;:&quot;pdf&quot;,&quot;work_url&quot;:&quot;https://www.academia.edu/39263350/Demything_human_error_by_re_analyzing_incidents_in_a_heavy_machinery_manufacturer&quot;,&quot;alternativeTracking&quot;:true}"><span class="material-symbols-outlined" style="font-size: 18px" translate="no">download</span><span class="ds2-5-text-link__content">Download free PDF</span></button><a class="ds2-5-text-link ds2-5-text-link--inline js-wsj-grid-card-view-pdf" href="https://www.academia.edu/39263350/Demything_human_error_by_re_analyzing_incidents_in_a_heavy_machinery_manufacturer"><span class="ds2-5-text-link__content">View PDF</span><span class="material-symbols-outlined" style="font-size: 18px" translate="no">chevron_right</span></a></div></div><div class="ds-related-work--container js-wsj-grid-card" data-collection-position="9" data-entity-id="30384689" data-sort-order="default"><a class="ds-related-work--title js-wsj-grid-card-title ds2-5-body-md ds2-5-body-link" href="https://www.academia.edu/30384689/Training_to_safety_rules_use_Some_reflections_on_a_case_study">Training to safety rules use. Some reflections on a case study</a><div class="ds-related-work--metadata"><a class="js-wsj-grid-card-author ds2-5-body-sm ds2-5-body-link" data-author-id="14671618" href="https://univ-nantes.academia.edu/ChristineVidalGomel">Christine Vidal-Gomel</a></div><p class="ds-related-work--abstract ds2-5-body-sm">This article proposes to consider training in occupational risk prevention as situated at the crossroads between regulated safety (based on prescribed safety rules and procedures)-and managed safety (based on operators&#39; knowledge and experience). A case study in the field of ready-mixed concrete delivery to worksites is presented. It demonstrates the redefinitions of a safety rule within companies, giving it little operational value for operators, and the resources that they have built with experience. These resources are also shown to be limited. Indeed, not everything can be learned through in situ experience and peer mediation. Thus, the &quot; professional knowledge of reference &quot; needs to be identified in order to design training content that combines the &quot;regulated safety&quot; and &quot;managed safety&quot; that are necessary to produce safe working conditions. This approach to training design, based on the analysis of activity in situ, represents a shift away from the technical-regulatory and behavioral approach that still dominates the field of training in occupational risk prevention.</p><div class="ds-related-work--ctas"><button class="ds2-5-text-link ds2-5-text-link--inline js-swp-download-button" data-signup-modal="{&quot;location&quot;:&quot;wsj-grid-card-download-pdf-modal&quot;,&quot;work_title&quot;:&quot;Training to safety rules use. Some reflections on a case study&quot;,&quot;attachmentId&quot;:50833623,&quot;attachmentType&quot;:&quot;pdf&quot;,&quot;work_url&quot;:&quot;https://www.academia.edu/30384689/Training_to_safety_rules_use_Some_reflections_on_a_case_study&quot;,&quot;alternativeTracking&quot;:true}"><span class="material-symbols-outlined" style="font-size: 18px" translate="no">download</span><span class="ds2-5-text-link__content">Download free PDF</span></button><a class="ds2-5-text-link ds2-5-text-link--inline js-wsj-grid-card-view-pdf" href="https://www.academia.edu/30384689/Training_to_safety_rules_use_Some_reflections_on_a_case_study"><span class="ds2-5-text-link__content">View PDF</span><span class="material-symbols-outlined" style="font-size: 18px" translate="no">chevron_right</span></a></div></div></div></div><div class="ds-sticky-ctas--wrapper js-loswp-sticky-ctas hidden"><div class="ds-sticky-ctas--grid-container"><div class="ds-sticky-ctas--container"><button class="ds2-5-button js-swp-download-button" data-signup-modal="{&quot;location&quot;:&quot;continue-reading-button--sticky-ctas&quot;,&quot;attachmentId&quot;:88730613,&quot;attachmentType&quot;:&quot;pdf&quot;,&quot;workUrl&quot;:null}">See full PDF</button><button class="ds2-5-button ds2-5-button--secondary js-swp-download-button" data-signup-modal="{&quot;location&quot;:&quot;download-pdf-button--sticky-ctas&quot;,&quot;attachmentId&quot;:88730613,&quot;attachmentType&quot;:&quot;pdf&quot;,&quot;workUrl&quot;:null}"><span class="material-symbols-outlined" style="font-size: 20px" translate="no">download</span>Download PDF</button></div></div></div><div class="ds-below-fold--grid-container"><div class="ds-work--container js-loswp-embedded-document"><div class="attachment_preview" data-attachment="Attachment_88730613" style="display: none"><div class="js-scribd-document-container"><div class="scribd--document-loading js-scribd-document-loader" style="display: block;"><img alt="Loading..." src="//a.academia-assets.com/images/loaders/paper-load.gif" /><p>Loading Preview</p></div></div><div style="text-align: center;"><div class="scribd--no-preview-alert js-preview-unavailable"><p>Sorry, preview is currently unavailable. 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18px" translate="no">download</span><span class="ds2-5-text-link__content">Download free PDF</span></button><a class="ds2-5-text-link ds2-5-text-link--inline js-related-work-grid-card-view-pdf" href="https://www.academia.edu/12223946/Framework_for_the_use_of_official_occupational_accident_investigations_as_a_learning_tool_Analysis_of_a_public_programme_for_accident_investigation_in_the_manufacturing_sector"><span class="ds2-5-text-link__content">View PDF</span><span class="material-symbols-outlined" style="font-size: 18px" translate="no">chevron_right</span></a></div></div><div class="ds-related-work--container js-related-work-sidebar-card" data-collection-position="6" data-entity-id="69744663" data-sort-order="default"><a class="ds-related-work--title js-related-work-grid-card-title ds2-5-body-md ds2-5-body-link" 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