Taking a mixed-methods approach to collision investigation: AcciMap, STAMP-CAST and PCM

The application of systematic accident analysis tools to investigate food safety incidents

Effective food safety (FS) management relies on the understanding of the factors that contribute to FS incidents (FSIs) and the means for their mitigation and control. This review aims to explore the application of systematic accident analysis tools to both design FS management systems (FSMSs) as well as to investigate FSI to identify contributive and causative factors associated with FSI and the means for their elimination or control. The study has compared and contrasted the diverse characteristics of linear, epidemiological, and systematic accident analysis tools and hazard analysis critical control point (HACCP) and the types and depth of qualitative and quantitative analysis they promote. Systematic accident analysis tools, such as the Accident Map Model, the Functional Resonance Accident Model, or the Systems Theoretical Accident Model and Processes, are flexible systematic approaches to analyzing FSI within a socio-technical food system which is complex and continually evolving. They can be applied at organizational, supply chain, or wider food system levels. As with the application of HACCP principles, the process is time-consuming and requires skilled users to achieve the level of systematic analysis required to ensure effective validation and verification of FSMS and revalidation and reverification following an FSI. Effective revalidation and reverification are essential to prevent recurrent FSI and to inform new practices and processes for emergent FS concerns and the means for their control.

Exploring improvisations in road safety in a low-income setting

Road collision types repeat themselves, especially in low- and middle-income countries (LMICs), where countermeasures are often improvised and implemented with little planning. At the Shahbag intersection in Dhaka, Bangladesh, speed bumps were quickly constructed at the exit of the intersection as an improvised road safety measure following the occurrence of a fatal collision, which eventually contributed to another collision between a truck and a car. The events influencing the improvisation decision, and that action's consequences, have been analysed using the Impromap methodology, a variation of the Accimap approach that focusses specifically on improvisation. The applicability of the Impromap as a systems-based approach to the road safety domain is assessed using the predictions described in Rasmussen's risk management framework, and corresponding countermeasures are proposed. The analysis shows that improvisation in the road safety domain is undesirable irrespective of the economic setting as it is likely to eventually contribute to secondary collisions.Practitioner summary: In this paper, the events influencing the improvisation decision following a road crash, and that action's consequences, have been analysed using the Impromap methodology. The applicability of Impromap as a systems-based approach in road safety domain is assessed using the Rasmussen's risk management framework-based predictions, and corresponding countermeasures are proposed.

Identification and analysis of hoisting safety risk factors for IBS construction based on the AcciMap and cases study

Hoisting is an essential aspect of Industrial Building System (IBS) construction. Although research on hoisting safety in China has made strides to focus on "worker," "data," "task," "site," and "accident," there still needs to be more approaches based on multi-dimensional social system thinking. Therefore, the paper aims to fill this gap. We investigated 105 hoisting accidents in China and found that hoisting accidents occurred most frequently in China's southeast coastal region; truck-mounted cranes and tower cranes were the most common types of machinery involved in accidents; hoisting load off, capsizing of crane machinery, and workers falling from height are the three most common accident types; the average impact of a single hoisting accident is approximately RMB 2.43 million direct economic loss, 1.543 deaths and 0.829 injured. This study used three algorithms (Rindge regression, Lasson regression, and partial least squares regression) to explore the impact of deaths and injuries on direct economic losses. By combining Rasmussen's risk framework with the characteristics of hoisting construction, six risk domains and thirty-six safety risk factors were identified. Finally, we used AcciMap technology to construct a qualitative IBS hoisting management model, which exhaustively presents the systematic levels and propagation paths of the influencing factors by the PDCA method. The research helps academics explore strategies to improve the safety of hoisting construction in IBS. Moreover, the study outcomes can inform the policy-making process towards promoting healthy and sustainable construction development.

Railway accident causation analysis: Current approaches, challenges and potential solutions

Railway accident causation analysis is fundamental to understanding the nature of railway safety. Although a considerable number of prior studies have investigated this context, many of them suffer from the need to deal with a large amount of textual data given that most railway safety-related information is recorded and stored in the form of text. To gain a better understanding of the limitations imposed by overreliance on textual analysis, a scoping review of the academic literature on how railway accident causation analysis is addressed has been conducted. The results confirm the high frequency of using textual data, a single case study, and in-depth analysis frameworks. While the value of exploring causational factors is clear, the high level of human intervention and the labour-intensive analysis processes based on a large volume of textual data hinder researchers from understanding the complex nature of the rail safety system. Recently, growing attention has been given to the application of Natural Language Processing (NLP) to aid the practice of analysing a large corpus of textual data, but only limited studies to date in railway safety use such techniques and none address railway accident causation analysis. To fill this gap, a supplementary review is conducted to identify opportunities, challenges, boundaries and limitations in the application of NLP approaches to railway accident causation analysis. Findings indicate that novel techniques using off-the-shelf tools have strong potential to overcome the limitations of overreliance on manual analysis in practice and theory, but the absence of shared railway safety-related benchmark corpora restricts implementation. This study sheds light on a new approach to railway accident causation analysis and clarifies future applicable utilisations for further research.

Examining Coroners' Recommendations for Health and Safety Management of Ageing Heavy Vehicle Drivers: A STAMP Analysis

Recommendations were analysed from coronial cases involving ageing heavy vehicle drivers (≥55 years) and mapped onto a Systems Theoretic Accident Model and Processes (STAMP) control structure to identify the controllers and control actions influential in the heavy vehicle industry with regard to health and safety. A National Coronial Information System (NCIS) database search revealed 38 coroners' recommendations arising from 14 unique cases of ageing driver involvement. There were no ageing themes identified in the analysis of coroners' findings and recommendations. An examination of the STAMP control structure identified that the highest concentration of recommendations was in the level of regulation, the second most senior level of control, although safety constraints were advised for all five levels of the system. In regard to identifying themes of control flaws in the recommendations, the study found that "unidentified hazards" were the most common type of safety failure in the analysis of cases of ageing drivers, concentrated at the regulatory level, which indicates that additional risk identification methods by upper levels of control are needed. Therefore, a recommendation arising from the current study is that additional controls in safety intervention are necessitated in the upper and middle levels of the road freight transportation system; in particular, formalising health and safety education for organisational managers, with a focus on identifying ageing issues, would fill a gap in the system for managing ageing heavy vehicle drivers. In conclusion, this study has found that improving the health and safety of ageing heavy vehicle drivers necessitates additional safety constraints with a focus on formalised safety education for organisational managers, in addition to a means to detect emerging and unforeseen hazards in the road freight transportation industry.

Learning from Incidents in Socio-Technical Systems: A Systems-Theoretic Analysis in the Railway Sector

Post mortem incident investigations are vital to prevent the occurrence of similar events and improve system safety. The increasing interactions of technical, human and organizational elements in modern systems pose new challenges for safety management, demanding approaches capable of complementing techno-centric investigations with social-oriented analyses. Hence, traditional risk analysis methods rooted in event-chain reactions and looking for individual points of failure are increasingly inadequate to deal with system-wide investigations. They normally focus on an oversimplified analysis of how work was expected to be conducted, rather than exploring what exactly occurred among the involved agents. Therefore, a detailed analysis of incidents beyond the immediate failures extending towards socio-technical threats is necessary. This study adopts the system-theoretic accident model and process (STAMP) and its nested accident analysis technique, i.e., causal analysis based on systems theory (CAST), to propose a causal incident analysis in the railway industry. The study proposes a hierarchical safety control structure, along with system-level safety constraints, and detailed investigations of the system’s components with the purpose of identifying physical and organizational safety requirements and safety recommendations. The analysis is contextualized in the demonstrative use of a railway case. In particular, the analysis is instantiated for a 2011 incident in the United Kingdom (UK) railway system. Hence, the CAST technique requires information regarding incidents, facts and processes. Therefore, the case study under analysis provided the information to analyze the accidents based on system theory, in which the results of the analysis prove the benefits of a CAST application to highlight criticalities at both element- and system-level, spanning from component failure to organizational and maintenance planning, enhancing safety performance in normal work practices.