Accident investigation reporting deficiencies related to organizational factors in machinery space fires and explosions

Human Factors Investigation of Ejection from a Roller Coaster

The Human Factors Analysis and Classification System (HFACS) was used to evaluate a complex forensic case. The use of HFACS in forensic human factors is demonstrated via a case study of the death of a roller coaster rider ejected from his seat. The analysis revealed systemic factors for the fatality throughout the amusement park and ride manufacturer organizations. Such system analyses are needed to move park management and state investigators away from their narrow focus on rider behavior as causes of injury incidents, and address systemic factors to make amusement parks safer for guests.

Cause Analysis of Unsafe Acts of Pilots in General Aviation Accidents in China with a Focus on Management and Organisational Factors

Objectives. General aviation (GA) safety has become a key issue worldwide and pilot errors have grown to be the primary cause of GA accidents. However, fewer empirical studies have examined the contribution of management and organizational factors for these unsafe acts. Flawed decisions at the organizational level have played key roles in the performance of pilots. This study provides an in-depth understanding of the management and organizational factors involved in GA accident reports. Methods. A total of 109 GA accidents in China between 1996 and 2021 were analysed. Among these reports, pilot-related accidents were analysed using the human factors analysis and classification system (HFACS) framework. Results. The significant effects of managerial and organizational factors and the failure pathways on GA accidents have been identified. Furthermore, unlike traditional HFACS-based analyses, the statistically significant relationships between failures at the organizational level and the sub-standard acts of the pilots in GA accidents were revealed. Conclusions. Such findings support that the GA accident prevention strategy that attempts to reduce the number of unsafe acts of pilots should be directed to the crucial causal categories at HFACS organizational levels: resource management, organizational process, failure to correct a known problem, inadequate supervision and supervisory violations.

Shipping Accidents Dataset: Data-Driven Directions for Assessing Accident’s Impact and Improving Safety Onboard

Recent tragic marine incidents indicate that more efficient safety procedures and emergency management systems are needed. During the 2014–2019 period, 320 accidents cost 496 lives, and 5424 accidents caused 6210 injuries. Ideally, we need historical data from real accident cases of ships to develop data-driven solutions. According to the literature, the most critical factor to the post-incident management phase is human error. However, no structured datasets record the crew’s actions during an incident and the human factors that contributed to its occurrence. To overcome the limitations mentioned above, we decided to utilise the unstructured information from accident reports conducted by governmental organisations to create a new, well-structured dataset of maritime accidents and provide intuitions for its usage. Our dataset contains all the information that the majority of the marine datasets include, such as the place, the date, and the conditions during the post-incident phase, e.g., weather data. Additionally, the proposed dataset contains attributes related to each incident’s environmental/financial impact, as well as a concise description of the post-incident events, highlighting the crew’s actions and the human factors that contributed to the incident. We utilise this dataset to predict the incident’s impact and provide data-driven directions regarding the improvement of the post-incident safety procedures for specific types of ships.

The Role of the Human Factor in Marine Accidents

A common interest of all shipping industry stakeholders is safe and accident-free shipping. To reach that goal, one of the most important actions that can be done is to analyze previous marine accidents. It means finding causes of accidents and, based on the analysis results, implementing effective corrective measures that can help reduce such undesired events in the future and improve safety efforts in shipping. Since it is widely accepted that human error accounts for 80–85% of all marine accidents, the research was focused on the human factor analysis in marine accidents. In this paper, 135 marine accident reports recorded in the UK Marine Accident Investigation Branch (MAIB) database from 2010 to 2019 were analyzed. The analysis aimed to categorize causal factors and discover the ones that are the most common. The Human Factor Analysis and Classification System for Maritime Accidents (HFACS-MA) method was used to be able to do so. Furthermore, multiple linear regression was used to determine the relationship between the number of accidents and the most common HFACS-MA causal factors. The research revealed that the causes of marine accidents are primarily dependent on two human factor categories and confirmed that by influencing those human factors categories, the number of marine accidents could be reduced and shipping safety improved in general.

Analyzing Collision, Grounding, and Sinking Accidents Occurring in the Black Sea Utilizing HFACS and Bayesian Networks

This study examines and analyzes marine accidents that have occurred over the past 20 years in the Black Sea. Geographic information system, human factor analysis and classification system (HFACS), and Bayesian network models are used to analyze the marine accidents. The most important feature distinguishing this study from other studies is that this is the first study to analyze accidents that have occurred across the whole Black Sea. Another important feature is the application of a new HFACS structure to reveal accident formation patterns. The results of this study indicate that accidents occurred in high concentrations in coastal regions of the Black Sea, especially in the Kerch Strait, Novorossiysk, Kilyos, Constanta, Riva, and Batumi regions. The formation of grounding and sinking accidents has been found to be similar in nature; the use of inland and old vessels has been highlighted as important factors in sinking and grounding incidents. However, the sequence of events leading to collision-contact accidents differs from the sequence of events resulting in grounding and sinking accidents. This study aims to provide information to the maritime industry regarding the occurrence of maritime incidents in the Black Sea, in order to assist with reduction and prevention of the marine accidents.

Identification of factors that influence occupational accidents in the petroleum industry: A qualitative approach

BACKGROUND

Exploring experiences of individuals for barriers they confront relating to safety could help to design safety interventions with an emphasis on the most safety influencing factors.

OBJECTIVE

This study strived to present an empirical exploration of individuals' experiences across the petroleum industry at different levels of the organizational structure for factors that influence occupational accidents.

METHOD

Based on accidents history, face-to-face semi-structured interviews were conducted with individuals who engaged in fatal activities, as well as authorities responsible for managing safety. The qualitative content analysis of 46 interview transcripts was conducted using MAXQDA software.

RESULTS

A three-layer model comprising organizational, supervisory and operator level influencing factors with 16 categories were found influence factors of occupational safety. The results highlighted the role of organizational factors, including inappropriate contract management, inadequate procedures, and issues relating to competency management and the organizational climate. Moreover, defects relating to the monitoring and supervision system were identified as important causes of accidents.

CONCLUSIONS

The findings demonstrated that the qualitative approach could reveal additional latent aspects of safety influencing factors, which require consideration for the appropriate management of occupational safety. This study can guide the planning of preventive strategies for occupational accidents in the petroleum industry.

The development and validation of a human factors analysis and classification system for the construction industry

Human factors significantly contribute to accidents and vary with the industries in which they exist. However, there are few analytical methods for human factors in the construction industry. Based on the prevalent human factor analysis and classification system (HFACS), the present study proposes a HFACS for the construction industry (HFACS-CI). Compared with the HFACS, the HFACS-CI develops Level 5 with classifications including 'the attitude of owner' and 'the regulation of engineering firm', and adds classifications, i.e., 'management for change' and 'management for subcontractors', to Level 4. Its validation is verified by application to the 2016 platform collapse in Fengcheng, Jiangxi, China. Finally, utilizing the χ² test and Apriori algorithm to explore the causalities among the classifications of the HFACS-CI, 'the attitude of owner', 'the regulation of engineering firm' and 'organizational climate' are identified as the human factors that may create conditions for the occurrence of other human factors.

Exploring the Contributory Factors of Confined Space Accidents Using Accident Investigation Reports and Semistructured Interviews

Background

The oil and gas industry is one of the riskiest industries for confined space injuries. This study aimed to understand an overall picture of the causal factors of confined space accidents through analyzing accident reports and the use of a qualitative approach.

Methods

Twenty-one fatal occupational accidents were analyzed according to the Human Factors Analysis and Classification System approach. Furthermore, thirty-three semistructured interviews were conducted with employees in different roles to capture their experiences regarding the contributory factors. The content analyses of the interview transcripts were conducted using MAXQDA software.

Results

Based on accident reports, the largest proportions of causal factors (77%) were attributed to the organizational and supervisory levels, with the predominant influence of the organizational process. We identified 25 contributory factors in confined space accidents that were causal factors outside of the original Human Factors Analysis and Classification System framework. Therefore, modifications were made to deal with factors outside the organization and newly explored causal factors at the organizational level. External Influences as the fifth level considered contributory factors beyond the organization including Laws, Regulations and Standards, Government Policies, Political Influences, and Economic Status categories. Moreover, Contracting/Contract Management and Emergency Management were two extra categories identified at the organizational level.

Conclusions

Preventing confined space accidents requires addressing issues from the organizational to operator level and external influences beyond the organization. The recommended modifications provide a basis for accident investigation and risk analysis, which may be applicable across a broad range of industries and accident types.

Half-century research developments in maritime accidents: Future directions

Over the past 50 years, research in maritime accidents has undergone a series of fundamental changes. Understanding the evolution of these changes can help maritime communities to know what has been done in the past, how maritime safety can be improved in the future, and how to reduce or eliminate the risks to ships, the lives aboard them, the cargo they carry, and the marine environment. This study conducts a comprehensive literature review on research in maritime accidents, comprising 572 papers published in 125 journals over the 50 years from 1965 to 2014. The patterns of evolution of the researchers, the journals, the disciplines involved, the research methods, the major issues and causes, and the data sources are identified, and the changes explained. We find that the main focus of research in maritime accidents has shifted over the past 50 years from naval architecture to human error, and may continue to expand into socio-economic factors. In addition, future research in maritime accidents will be multi-disciplinary, use multiple data sources, and adopt advanced research methods, to account for complex interactions between the natural environment, the development of naval technology, human behavior, and shipping market conditions.

Design and application of a tool for structuring, capitalizing and making more accessible information and lessons learned from accidents involving machinery

Accident reports are published in order to communicate the information and lessons learned from accidents. An efficient accident recording and analysis system is a necessary step towards improvement of safety. However, currently there is a shortage of efficient tools to support such recording and analysis. In this study we introduce a flexible and customizable tool that allows structuring and analysis of this information. This tool has been implemented under TEEXMA®. We named our prototype TEEXMA®SAFETY. This tool provides an information management system to facilitate data collection, organization, query, analysis and reporting of accidents. A predefined information retrieval module provides ready access to data which allows the user to quickly identify the possible hazards for specific machines and provides information on the source of hazards. The main target audience for this tool includes safety personnel, accident reporters and designers. The proposed data model has been developed by analyzing different accident reports.

Human and organisational factors in maritime accidents: analysis of collisions at sea using the HFACS

Over the last decade, the shipping industry has implemented a number of measures aimed at improving its safety level (such as new regulations or new forms of team training). Despite this evolution, shipping accidents, and particularly collisions, remain a major concern. This paper presents a modified version of the Human Factors Analysis and Classification System, which has been adapted to the maritime context and used to analyse human and organisational factors in collisions reported by the Marine Accident and Investigation Branch (UK) and the Transportation Safety Board (Canada). The analysis shows that most collisions are due to decision errors. At the precondition level, it highlights the importance of the following factors: poor visibility and misuse of instruments (environmental factors), loss of situation awareness or deficit of attention (conditions of operators), deficits in inter-ship communications or Bridge Resource Management (personnel factors). At the leadership level, the analysis reveals the frequent planning of inappropriate operations and non-compliance with the Safety Management System (SMS). The Multiple Accident Analysis provides an important finding concerning three classes of accidents. Inter-ship communications problems and Bridge Resource Management deficiencies are closely linked to collisions occurring in restricted waters and involving pilot-carrying vessels. Another class of collisions is associated with situations of poor visibility, in open sea, and shows deficiencies at every level of the socio-technical system (technical environment, condition of operators, leadership level, and organisational level). The third class is characterised by non-compliance with the SMS. This study shows the importance of Bridge Resource Management for situations of navigation with a pilot on board in restricted waters. It also points out the necessity to investigate, for situations of navigation in open sea, the masters' decisions in critical conditions as well as the causes of non-compliance with SMS.