Near-miss incident management in the chemical process industry

Relationship Between Companies' Responses to Near-Miss Reports and Turnover Intentions of Workers: A Nationwide Cross-Sectional Study

Background

Effective near-miss management is important in preventing workplace accidents. A company's inadequate response to near-miss reports can lead workers to feel insecure and dissatisfied with the company. We investigated the relationship between companies' responses to near-miss reports and turnover intentions of workers.

Methods

We conducted a cross-sectional study using online self-administered questionnaire survey to workers aged ≥20 years in Japan in March 2022. The analysis included 5,071 participants who had near-miss experiences and reported them to their companies. The independent variable was companies' responses to near-miss reports, classified into three categories: adequate response group, inadequate response group, and no response group. The dependent variable was turnover intentions. We calculated the odds ratio and 95% confidential interval (CI) using multilevel logistic regression analyses nested for industries and adjusted for covariates.

Results

Of the 5,071 participants, 3,058 (60.3%) were adequate response group, 1,484 (29.3%) were inadequate response group, and 529 (10.4%) were no response group. In multivariable adjusted model, compared with adequate response group, the odds ratio of inadequate response group and no response group were 1.80 (95% CI: 1.56-2.08) and 2.63 (95% CI: 2.15-3.22), respectively.

Conclusion

Our results suggested that there was a relationship between companies' responses to the near-miss reports and turnover intentions of workers. It is important not only to collect near-misses but also to respond appropriately to the reports and provide feedback to workers.

The influence of hazard control and prevention toward safety behaviors and safety outcomes in coal-fired power plants using PLS-SEM

INTRODUCTION

The electrical utility industry, which plays a vital role in sustaining other sectors, contributes to high occupational accident rates in the utility industries. The high accident rate shows that there has been insufficient effort made to control unsafe actions and conditions in the workplace. This study aims to examine the influence of hazard control and prevention as leading indicators of safety behaviors and outcomes in coal-fired power plants in Malaysia.

METHODS

This quantitative research was conducted by distributing survey questionnaires randomly to five coal-fired power plants in Peninsular Malaysia. A total of 340 respondents were involved in this research. Partial least squares structural equation modeling (PLS-SEM) analysis was performed using SmartPLS to validate and examine the relationship of the proposed model.

RESULTS

The results validate the construct of hazard control and prevention consisting of planning, action, managing, and verifying, while the safety outcomes construct consists of occupational accidents, fatal accidents, near misses, and lost time injuries. The results indicate that hazard control and prevention significantly relate to safety compliance, safety participation, safety motivation, and safety knowledge. Moreover, safety outcomes were influenced negatively by hazard control and prevention through safety compliance.

CONCLUSION

The model provides a better understanding of the influence of hazard control and prevention on safety behavior and outcomes.

PRACTICAL APPLICATIONS

The model can be used as guidance for practitioners and researchers in planning and implementing hazard control and prevention to improve health and safety in the workplace.

Improving Safety Performance of Construction Workers through Learning from Incidents

Learning from incidents (LFI) is a process to seek, analyse, and disseminate the severity and causes of incidents, and take corrective measures to prevent the recurrence of similar events. However, the effects of LFI on the learner's safety performance remain unexplored. This study aimed to identify the effects of the major LFI factors on the safety performance of workers. A questionnaire survey was administered among 210 construction workers in China. A factor analysis was conducted to reveal the underlying LFI factors. A stepwise multiple linear regression was performed to analyse the relationship between the underlying LFI factors and safety performance. A Bayesian Network (BN) was further modelled to identify the probabilistic relational network between the underlying LFI factors and safety performance. The results of BN modelling showed that all the underlying factors were important to improve the safety performance of construction workers. Additionally, sensitivity analysis revealed that the two underlying factors-information sharing and utilization and management commitment-had the largest effects on improving workers' safety performance. The proposed BN also helped find out the most efficient strategy to improve workers' safety performance. This research may serve as a useful guide for better implementation of LFI practices in the construction sector.

Improving Safety Management through Analysis of Near-Miss Reports—A Tanker Ship Case Study

A near-miss management system (NMMS) is a tool used for improving safety at sea if adequately implemented. Valuable knowledge to improve safety management might be gained by investigating and analysing reported events. Therefore, it is of the utmost importance to report each observed near-miss event. Because tankers are generally considered dangerous, but at the same time safe due to stringent requirements, near-miss reports and NMMS policy were collected from one oil tanker ship. Data were pre-processed and analysed. Variables used during analysis were near-miss type, risk level, ship position, and onboard location of near-miss occurrence. Analysis of policy and reports revealed that most near misses occurred on the deck area, but higher-risk-level events were reported in the engine room and navigating bridge. Housekeeping, equipment failure, use of personal protective equipment (PPE), and process-/procedure-related events were most common and generally related to lower risk levels. The most frequent corrective actions recorded were implementing safe working practices and PPE. In addition, higher-risk-level events were related to less effective corrective actions. Based on the findings, suggestions for improvements include promoting safe behaviour and adequate PPE usage through additional training, ensuring proper housekeeping, regular maintenance of shipboard equipment and spare parts management, and toolbox meetings and risk assessments that include conclusions of near-miss investigations and analysis.

Analysis of ergonomic occupational accidents and near misses in a large Belgian university hospital

INTRODUCTION

Health-care organizations are facing a high burden of ergonomic occupational accidents, and prevention is a continuous point of interest. In this manuscript, we describe the characteristics of ergonomic accidents in a large Belgian university hospital and discuss the value of near misses.

METHODS

Combining databases, we identified the frequency [number of accidents × 10⁶ hours worked per year], severity (number of days off work × 10³ hours worked per year), and profile of the victims of occupational ergonomic accidents (with absence from work) or incidents or near-misses (without absence from work). Ergonomic accidents and incidents include slips, trips, falls, injurious body movements, overexertion, and handling heavy weights.

RESULTS

In a period of 23 years, we noticed a significant decrease in the frequency of ergonomic accidents (from about 7 to about 4 standard units), without changes in the severity. The decrease in the frequency of accidents is mirrored by an increase in the frequency of incidents (from about 4 to about 6 standard units). Female and older employees are more vulnerable to accidents, and the frequency was between two and four times higher for employees mostly involved in manual tasks compared to employees mostly involved in managerial tasks. The profile of the victims and the causes of accidents and incidents were identical.

CONCLUSION

Although it is premature to assume a cause-consequence relationship between incidents and accidents, it is tempting to speculate that the increased ratio of the frequencies of incidents over accidents might be one of the variables reflecting the adequacy of preventive measures and the growth of safety behavior.

Investigating Barriers to Accident Precursor Reporting in East Azerbaijan Gas Company from the Perspective of HSE Officers - A Qualitative Study

BackgroundInvestigating the root causes of under-reporting these cases is very important. The aim of this study was investigating barriers to near-misses reporting in East Azerbaijan Gas Company from the perspective of Health, Safety and Environment (HSE) officers.MethodsThe semi-structured individual interviews were used and 21 interviews were conducted with HSE officers. Inductive content analysis was used for analyzing interviews. After analyzing the interviews, the codes in the interviews were categorized.ResultsIn general, two categories of code were created: 1- Reasons for non-reporting of accident precursors 2- Suggested solutions to improve the reporting system of accident precursors. However, two main categories were found for not reporting: individual reasons such as lack of commitment to the job, lack of attention to social responsibility, forgetfulness and laches in reporting etc and organization reasons such as job instability among employees, lack of sufficient training, Failure to provide feedback by the organization etc.ConclusionIn this study, it was found that the opinions of people working in the organization can be very effective in promoting reporting, so any organization can choose the appropriate strategy to increase the number and quality of reports by examining the opinions of managers, HSE officers and workers working in the organization.

Second-order problem solving: Nurses' perspectives on learning from near misses

OBJECTIVES

Near misses happen more frequently than actual errors, and highlight system vulnerabilities without causing any harm, thus provide a safe space for organizational learning. Second-order problem solving behavior offers a new perspective to better understand how nurses promote learning from near misses to improve organizational outcomes. This study aimed to explore frontline nurses' perspectives on using second-order problem solving behavior in learning from near misses to improve patient safety.

METHODS

A qualitative exploratory study design was employed. This study was conducted in three tertiary hospitals in east China from June to November 2015. Purposive sampling was used to recruit 19 frontline nurses. Semi-structured interviews and a qualitative directed content analysis was undertaken using Crossan's 4I Framework of Organizational Learning as a coding framework.

RESULTS

Second-order problem solving behavior, based on the 4I Framework of Organizational Learning, was referred to as being a leader in exposing near misses, pushing forward the cause analysis within limited capacity, balancing the active and passive role during improvement project, and promoting the continuous improvement with passion while feeling low-powered.

CONCLUSIONS

4I Framework of Organizational Learning can be an underlying guide to enrich frontline nurses' role in promoting organizations to learn from near misses. In this study, nurses displayed their pivotal role in organizational learning from near misses by using second-order problem solving. However, additional knowledge, skills, and support are needed to maximize the application of second-order problem solving behavior when near misses are recognized.

Generalized linear mixed hidden semi-Markov models in longitudinal settings: A Bayesian approach

Hidden Markov and semi-Markov models (H(S)MMs) constitute useful tools for modeling observations subject to certain dependency structures. The hidden states render these models very flexible and allow them to capture many different types of latent patterns and dynamics present in the data. This has led to the increased popularity of these models, which have been applied to a variety of problems in various domains and settings, including longitudinal data. In many longitudinal studies, the response variable is categorical or count-type. Generalized linear mixed models (GLMMs) can be used to analyze a wide range of variables, including categorical and count. The present study proposes a model that combines HSMMs with GLMMs, leading to generalized linear mixed hidden semi-Markov models (GLM-HSMMs). These models can account for time-varying unobserved heterogeneity and handle different response types. Parameter estimation is achieved using a Monte Carlo Newton-Raphson (MCNR)-like algorithm. In our proposed model, the distribution of the random effects depends on hidden states. We illustrate the applicability of GLM-HSMMs with an example in the field of occupational health, where the response variable consists of count values. Furthermore, we assess the performance of our MCNR-like algorithm through a simulation study.

Reporting as a Key Element of an Effective Near-Miss Management System in Shipping

Shipping is a high-risk industry and prone to accidents. A near-miss management system is an important aspect of the safety performance in shipping because the causes are the same for near-misses and accidents. Reporting, analyzing, and learning from near-misses can prevent the recurrence of accidents and thus improve safety on ships. This paper addresses near-miss management systems in shipping and provides insights into the quality of the implementation of these systems, with an emphasis on the importance of reporting. Research data were derived from two surveys and supported by data gained from near-miss reports and existing literature reviews. Professional seafarers of various ranks, ages, nationalities, and experiences, serving on tankers, cruise ships, bulk carriers, and container ships, voluntarily participated in these surveys. The first survey comprised 223 participants, and the second survey involved 22 participants. The research results indicate that near-miss reporting is inadequate, and several barriers limit appropriate near-miss reporting. The difficulty of seafarers in identifying near-miss events was found to be one of the major barriers to near-miss reporting at sea. Based on this research, a conceptual model of a near-miss management system was developed, and measures that can be applied to overcome barriers and increase reporting are proposed.

Learning from Incidents: A Supply Chain Management Perspective in Military Environments

Supply chain management (SCM) represents a crucial role in the military sector to ensure operation sustainability. Starting from the NATO handbook for military organizational learning, this paper aims at investigating the link between technical inconveniences and sustainable supply chain operations. Taking advantage of the learning from incidents (LFI) models traditionally used in the risk and safety management area, this paper proposes an information management system to support organizational learning from technical inconveniences in a military supply chain. The approach is discussed with reference to the Italian context, in line with international and national standards for technical inconvenience reporting. The results of the paper show the benefits of adopting a systematic LFI system for technical inconveniences, providing related exemplar business intelligence dashboards. Further implications for the generalization of the proposed information management system are presented to foster a healthy and effective reporting environment in military scenarios.

Investigating the status of accident precursor management in East Azarbaijan Province Gas Company

Purpose. The accident precursor reporting system is a key point in preventing accidents and proper functioning of this system is critical. In the present study, the accident precursor reporting system in the Iranian East Azarbaijan Province Gas Company was investigated. Methods. This quantitative-qualitative study used field survey and document review methods to determine how the company was reporting. Qualitative content analysis approaches were used to analyze the reporting system over a 3-year period. From 1209 accident precursor reports, 2271 codes were extracted. Finally, these codes were reduced to three clusters: 996 (43.86%), 447 (19.68%) and 828 (36.46%) codes related to near misses, unsafe conditions and unsafe acts, respectively. A χ² test was used to investigate the reporting process. Results. Reporting rates varied by time (e.g., people reported more accident precursors in the first 6 solar months), by area (some areas had higher reporting rates than others) and by type of job (operational jobs had the highest reporting rate [73.16%] compared to non-operational jobs [26.84%]). Conclusion. It was suggested that policy-makers should improve the accident precursor reporting system. Changes to the current reporting system are essential to help in the prevention of future unpleasant accidents.

Behavioral Determinants of Target Shifting and Deterrence in an Analog Cyber-Attack Game

This study examines how exploiting biases in probability judgment can enhance deterrence using a fixed allocation of defensive resources. We investigate attacker anchoring heuristics for conjunctive events with missing information to distort attacker estimates of success for targets with equal defensive resources. We designed and conducted a behavioral experiment functioning as an analog cyber attack with multiple targets requiring three stages of attack to successfully acquire a target. Each stage is associated with a probability of successfully attacking a layer of defense, reflecting the allocation of resources for each layer. There are four types of targets that have nearly equal likelihood of being successfully attacked, including one type with equally distributed success probabilities over every layer and three types with success probabilities that are concentrated to be lowest in the first, second, or third layer. Players are incentivized by a payoff system that offers a reward for successfully attacked targets and a penalty for failed attacks. We collected data from a total of 1,600 separate target selections from 80 players and discovered that the target type with the lowest probability of success on the first layer was least preferred among attackers, providing the greatest deterrent. Targets with equally distributed success probabilities across layers were the next least preferred among attackers, indicating greater deterrence for uniform-layered defenses compared to defenses that are concentrated at the inner (second or third) levels. This finding is consistent with both attacker anchoring and ambiguity biases and an interpretation of failed attacks as near misses.

The Correlation between Knowledge, Attitudes toward Occupational Safety and Health and Near Miss

Introduction: The results of the research conducted by Frank Bird concluded that every occupational safety and health is preceded by a near-injury occurrence or near miss. Near miss is an incidence that potentially causes loss, which is triggered by direct factors, namely unsafe action, and unsafe conditions, and basic factors, such as workers and works. The workers as a basic factor comprise their knowledge and attitudes towards occupational safety and health-related to personal protective equipment (PPE). Methods: This research is descriptive research that aims to identify the strength of the relationship between the knowledge and attitudes toward occupational safety and health that is related to PPE in the Outfitting Unit at PT. Dok dan Perkapalan Surabaya by applying the cross-sectional design. The data is obtained by questionnaire and interview. The questionnaire is distributed to all 30 workers in the Outfitting Unit at PT. Dok dan Perkapalan Surabaya. Results: Indicate that the majority of the workers experience a low-level of near-miss (90%), while the other 10% experience a moderate-level of near-miss. The correlation coefficient value as many as 0.149 denotes that there is a weak relationship between the workers’ knowledge of occupational safety and health and a near miss. Similarly, the relationship between the workers’ attitudes toward occupational safety and health regarding PPR and near-miss is also a weak relationship with the correlation coefficient value of 0.236. In conclusion, it is affirmed that effective communication between units and the provision of PPE are the factors that cause the occurrence of near-miss in the company. Keywords: attitude, knowledge, near miss

Safety-Specific Leadership, Goal Orientation, and Near-Miss Recognition: The Cross-Level Moderating Effects of Safety Climate

Near-miss recognition is an increasingly important area of research in safety management. Drawing on the self-determination theory, we ask whether and how safety-specific transformational leadership and safety-specific active transactional leadership promote near-miss recognition. We also explore the boundary condition by focusing on the moderating role of safety climate. We analyzed time-lagged data from 370 participants, and found that safety-specific transformational leadership enhances employees' near-miss recognition (by enhancing their learning goal orientation), and that safety-specific active transactional leadership also positively influences employees' near-miss recognition (by stimulating their performance goal orientation). In addition, we show that safety climate strengthens the relationship between safety-specific transactional leadership and employees' performance goal orientation, but does not affect the relationship between safety-specific transformational leadership and employees' learning goal orientation. We discuss the implications and limitations of the research.

Exploring the Potential Use of Near-Miss Information to Improve Construction Safety Performance

Construction project management usually has a high risk of safety-related accidents. An opportunity to proactively improve safety performance is with near-miss information, which is regarded as free lessons for safety management. The research status and practice; however, presents a lack of comprehensive understanding on what near-miss information means within the context of construction safety management. The objective of this study is to fill in this gap. The main findings enrich the comprehensive understanding of the near-miss definition, the near-miss causation model, and the process of near-miss management. Considering that near-misses are more tacit and obscure than accidents, the process for near-miss management involves eight stages: discovery, reporting, identification, prioritization, causal analysis, solution, dissemination, and evaluation. The first three stages aim to make near-misses explicit. The other five are adopted to better manage near-miss information, compiled in a well-designed near-miss database (NMDB). Finally, a case study was conducted to show how near-miss information can be utilized to assist in construction safety management. The main potential contributions here are twofold. Firstly, corresponding findings provide a knowledge framework of near-miss information for construction safety researchers who can go on to further study near-miss management. Secondly, the proposed framework contributes to the guidance and encouragement of near-miss practices on construction sites.

Application of Bayesian Networks and Information Theory to Estimate the Occurrence of Mid-Air Collisions Based on Accident Precursors

This paper combines Bayesian networks (BN) and information theory to model the likelihood of severe loss of separation (LOS) near accidents, which are considered mid-air collision (MAC) precursors. BN is used to analyze LOS contributing factors and the multi-dependent relationship of causal factors, while Information Theory is used to identify the LOS precursors that provide the most information. The combination of the two techniques allows us to use data on LOS causes and precursors to define warning scenarios that could forecast a major LOS with severity A or a near accident, and consequently the likelihood of a MAC. The methodology is illustrated with a case study that encompasses the analysis of LOS that have taken place within the Spanish airspace during a period of four years.

Near Misses in Financial Trading: Skills for Capturing and Averting Error

OBJECTIVE

The aims of this study were (a) to determine whether near-miss incidents in financial trading contain information on the operator skills and systems that detect and prevent near misses and the patterns and trends revealed by these data and (b) to explore if particular operator skills and systems are found as important for avoiding particular types of error on the trading floor.

BACKGROUND

In this study, we examine a cohort of near-miss incidents collected from a financial trading organization using the Financial Incident Analysis System and report on the nontechnical skills and systems that are used to detect and prevent error in this domain.

METHOD

One thousand near-miss incidents are analyzed using distribution, mean, chi-square, and associative analysis to describe the data; reliability is provided.

RESULTS

Slips/lapses (52%) and human-computer interface problems (21%) often occur alone and are the main contributors to error causation, whereas the prevention of error is largely a result of teamwork (65%) and situation awareness (46%) skills. No matter the cause of error, situation awareness and teamwork skills are used most often to detect and prevent the error.

CONCLUSION

Situation awareness and teamwork skills appear universally important as a "last line" of defense for capturing error, and data from incident-monitoring systems can be analyzed in a fashion more consistent with a "Safety-II" approach.

APPLICATION

This research provides data for ameliorating risk within financial trading organizations, with implications for future risk management programs and regulation.

Examining Factors that Influence the Existence of Heinrich's Safety Triangle Using Site-Specific H&S Data from More than 25,000 Establishments

In the 1930s, Heinrich established one of the most prominent and enduring accident prevention theories when he concluded that high severity occupational safety and health (OSH) incidents are preceded by numerous lower severity incidents and near misses. Seventy-five years of theory expansion/interpretation includes two fundamental tenets: (1) the ratio of lower to higher severity incidents exists in the form of a "safety-triangle" and (2) similar causes underlie both high and low severity events. Although used extensively to inform public policy and establishment-level health and safety priorities, recent research challenges the validity of the two tenets. This study explored the validity of the first tenet, the existence of the safety triangle. The advantage of the current study is the use of a detailed, establishment-specific data set that evaluated over 25,000 establishments over a 13-year time period, allowing three specific questions to be explored: (1) Are an increased number of lower severity incidents at an establishment significantly associated with the probability of a fatal event over time? (2) At the establishment level, do the effects of OSH incidents on the probability of a fatality over time decrease as the degree of severity decreases-thereby taking the form of a triangle? and (3) Do distinct methods for delineating incidents by severity affect the existence of the safety triangle form? The answer to all three questions was yes with the triangle form being dependent upon how severity was delineated. The implications of these findings in regard to Heinrich's theory and OSH policy and management are discussed.

A preliminary analysis of incident investigation reports of an integrated steel plant: some reflection

Large integrated steel plants employ an effective safety management system and gather a significant amount of safety-related data. This research intends to explore and visualize the rich database to find out the key factors responsible for the occurrences of incidents. The study was carried out on the data in the form of investigation reports collected from a steel plant in India. The data were processed and analysed using some of the quality management tools like Pareto chart, control chart, Ishikawa diagram, etc. Analyses showed that causes of incidents differ depending on the activities performed in a department. For example, fire/explosion and process-related incidents are more common in the departments associated with coke-making and blast furnace. Similar kind of factors were obtained, and recommendations were provided for their mitigation. Finally, the limitations of the study were discussed, and the scope of the research works was identified.

Basic Scholarship in Biosafety Is Critically Needed To Reduce Risk of Laboratory Accidents

Our firm conducted a risk/benefit assessment of “gain-of-function” research, as part of the deliberative process following a U.S. moratorium on the research (U.S. Department of Health and Human Services, U.S. Government Gain-of-Function Deliberative Process and Research Funding Pause on Selected Gain-of-Function Research Involving Influenza, MERS, and SARS Viruses, 2014).

Our firm conducted a risk/benefit assessment of “gain-of-function” research, as part of the deliberative process following a U.S. moratorium on the research (U.S. Department of Health and Human Services, U.S. Government Gain-of-Function Deliberative Process and Research Funding Pause on Selected Gain-of-Function Research Involving Influenza, MERS, and SARS Viruses, 2014). Due to significant missing but theoretically acquirable data, our biosafety assessment faced limitations, and we were forced to provide a relative, instead of absolute, measure of risk (Gryphon Scientific, LLC, Risk and Benefit Analysis of Gain of Function Research, 2016). Here, we argue that many of these types of missing data represent large and stunning gaps in our knowledge of biosafety and argue that these missing data, once acquired via primary research efforts, would improve biosafety risk assessments and could be incorporated into biosafety practices to reduce risk of accidents. Governments invest billions in biological research; at least a small fraction of this support is warranted to prevent biological accidents.

A near-miss management system architecture for the forensic investigation of software failures

Digital forensics has been proposed as a methodology for doing root-cause analysis of major software failures for quite a while. Despite this, similar software failures still occur repeatedly. A reason for this is the difficulty of obtaining detailed evidence of software failures. Acquiring such evidence can be challenging, as the relevant data may be lost or corrupt following a software system's crash. This paper proposes the use of near-miss analysis to improve on the collection of evidence for software failures. Near-miss analysis is an incident investigation technique that detects and subsequently analyses indicators of failures. The results of a near-miss analysis investigation are then used to detect an upcoming failure before the failure unfolds. The detection of these indicators - known as near misses - therefore provides an opportunity to proactively collect relevant data that can be used as digital evidence, pertaining to software failures. A Near Miss Management System (NMS) architecture for the forensic investigation of software failures is proposed. The viability of the proposed architecture is demonstrated through a prototype.

Major Accidents (Gray Swans) Likelihood Modeling Using Accident Precursors and Approximate Reasoning

Compared to the remarkable progress in risk analysis of normal accidents, the risk analysis of major accidents has not been so well-established, partly due to the complexity of such accidents and partly due to low probabilities involved. The issue of low probabilities normally arises from the scarcity of major accidents' relevant data since such accidents are few and far between. In this work, knowing that major accidents are frequently preceded by accident precursors, a novel precursor-based methodology has been developed for likelihood modeling of major accidents in critical infrastructures based on a unique combination of accident precursor data, information theory, and approximate reasoning. For this purpose, we have introduced an innovative application of information analysis to identify the most informative near accident of a major accident. The observed data of the near accident were then used to establish predictive scenarios to foresee the occurrence of the major accident. We verified the methodology using offshore blowouts in the Gulf of Mexico, and then demonstrated its application to dam breaches in the United Sates.

Near-misses and future disaster preparedness

Disasters garner attention when they occur, and organizations commonly extract valuable lessons from visible failures, adopting new behaviors in response. For example, the United States saw numerous security policy changes following the September 11 terrorist attacks and emergency management and shelter policy changes following Hurricane Katrina. But what about those events that occur that fall short of disaster? Research that examines prior hazard experience shows that this experience can be a mixed blessing. Prior experience can stimulate protective measures, but sometimes prior experience can deceive people into feeling an unwarranted sense of safety. This research focuses on how people interpret near-miss experiences. We demonstrate that when near-misses are interpreted as disasters that did not occur and thus provide the perception that the system is resilient to the hazard, people illegitimately underestimate the danger of subsequent hazardous situations and make riskier decisions. On the other hand, if near-misses can be recognized and interpreted as disasters that almost happened and thus provide the perception that the system is vulnerable to the hazard, this will counter the basic "near-miss" effect and encourage mitigation. In this article, we use these distinctions between resilient and vulnerable near-misses to examine how people come to define an event as either a resilient or vulnerable near-miss, as well as how this interpretation influences their perceptions of risk and their future preparedness behavior. Our contribution is in highlighting the critical role that people's interpretation of the prior experience has on their subsequent behavior and in measuring what shapes this interpretation.

Interpreting MSHA citations through the lens of occupational health and safety management systems: investigating their impact on mine injuries and illnesses 2003-2010

Since the late 1980s, the U.S. Department of Labor has considered regulating a systems approach to occupational health and safety management. Recently, a health and safety management systems (HSMS) standard has returned to the regulatory agenda of both the Occupational Safety and Health Administration (OSHA) and the Mine Safety and Health Administration (MSHA). Because a mandated standard has implications for both industry and regulating bodies alike, it is imperative to gain a greater understanding of the potential effects that an HSMS regulatory approach can have on establishment-level injuries and illnesses. Through the lens of MSHA's regulatory framework, we first explore how current enforcement activities align with HSMS elements. Using MSHA data for the years 2003-2010, we then analyze the relationship between various types of enforcement activities (e.g., total number of citations, total penalty amount, and HSMS-aligned citations) and mine reportable injuries. Our findings show that the reduction in mine reportable injuries predicted by increases in MSHA enforcement ranges from negligible to 18%. The results suggest that the type and focus of the enforcement activity may be more important for accident reduction than the total number of citations issued and the associated penalty amount.

Keep your eyes on the road: young driver crash risk increases according to duration of distraction

PURPOSE

Secondary task engagement that distracts the driver is a contributing factor to motor vehicle crashes among adults. However, the association between eye glance duration and crash risk with novice teenage drivers has not been determined.

METHODS

Vehicles of 42 newly licensed teenage drivers were instrumented with cameras, accelerometers, Global Positioning System(s) (GPS), and other devices. Data were collected continuously for 18 months. Crashes and near crashes (CNCs) were identified by examining highly elevated gravitational force events. Video footage of the 6 seconds prior to each CNC and randomly sampled non-CNC road segments were coded for the duration of eye glances off the forward roadway and the presence of secondary task engagement. The likelihood (odds ratios) of CNC due to eye glance behavior was calculated by comparing the prevalence of secondary task engagement and duration of eyes off road prior to CNC with the prevalence and duration of eyes off road during non-CNC road segments.

RESULTS

Crash risk increased with the duration of single longest glance during all secondary tasks (OR=3.8 for >2 s) and wireless secondary task engagement (OR=5.5 for >2 s). Single longest glance provided a more consistent estimate of crash risk than total time eyes off the forward roadway.

CONCLUSIONS

Those eye glances away from the forward roadway involving secondary tasks increased the likelihood of CNC. The longer the duration of eye glance away from the road the greater the risk, regardless of type of secondary task. Education and policy discouraging secondary task engagement, particularly for prolonged periods, is warranted.

Application of disability-adjusted life years to predict the burden of injuries and fatalities due to public exposure to engineering technologies

Background

As a public safety regulator, the Technical Standards and Safety Authority (TSSA) of Ontario, Canada predicts and measures the burden of injuries and fatalities as its primary means of characterizing the state of public safety and for decision-making purposes through the use of a simulation model. The paper proposes a simulation-based predictive model and the use of disability-adjusted life years (DALYs) as a population health metric for the purposes of reporting, benchmarking, public safety decision-making, and organizational goal setting. The proposed approach could be viewed as advancement in the application of traditional population health metrics, used primarily for public health policy decisions, for the measurement and prediction of safety risks across a wide variety of engineering technologies to which the general public is exposed.

Results

The proposed model is generic and applicable to a wide range of devices and technologies that are typically used by the general public. As an example, a measure of predicted risk that could result from the use of and exposure to elevating devices in the province of Ontario is presented in terms of the DALY metric. The predictions are further categorized in terms of the causal attribution of the risks for the purposes of identifying and focusing decision-making efforts. The results are also presented by taking into consideration factors such as near-misses or precursor events as termed in certain industries.

Conclusions

The ability to predict potential health impacts has three significant advantages for a public safety regulator – external reporting, decision-making to ensure public safety, and organizational benchmarking. The application of the well-known Monte Carlo simulation has been proposed to predict the health impacts expressed in terms of DALYs. The practicality of the proposed ideas has been demonstrated through the application of the prediction model to characterizing and managing risks associated with elevating devices in the province of Ontario, Canada.

The Shelf Life of a Safety Climate Assessment: How Long Until the Relationship with Safety-Critical Incidents Expires?

PURPOSE

This study investigates safety climate as both a leading (climate → incident) and a lagging (incident → climate) indicator of safety-critical incidents. This study examines the "shelf life" of a safety climate assessment and its relationships with incidents, both past and future, by examining series of incident rates in order to determine when these predictive relationships expire.

DESIGN/METHODOLOGY/APPROACH

A survey was conducted at a large, multinational chemical manufacturing company, with 7,467 responses at 42 worksites in 12 countries linked to over 14,000 incident records during the 2 years prior and 2 years following the survey period. Regressions revealed that safety climate predicts incidents of varying levels of severity, but it predicts the most severe incidents over the shortest period of time. The same is true for incidents predicting safety climate, with more severe incidents having a shorter predictive window. For the most critical relationship (climate predicting more severe incidents), the ability of a safety climate assessment to predict incidents expires after 3 months.

IMPLICATIONS

The choice of aggregation period in constructing incident rates is essential in understanding the safety climate-incident relationship. The common yearly count of incidents would make it seem that more severe incidents cannot be predicted by safety climate and also fails to show the strongest predictive effects of less severe incidents.

ORIGINALITY/VALUE

This research is the first to examine assumptions regarding aggregation periods when constructing safety-related incident rates. Our work guides organizations in planning their survey program, recommending more frequent measurement of safety climate.

Retrospective record review in proactive patient safety work - identification of no-harm incidents

Background

In contrast to other safety critical industries, well-developed systems to monitor safety within the healthcare system remain limited. Retrospective record review is one way of identifying adverse events in healthcare. In proactive patient safety work, retrospective record review could be used to identify, analyze and gain information and knowledge about no-harm incidents and deficiencies in healthcare processes. The aim of the study was to evaluate retrospective record review for the detection and characterization of no-harm incidents, and compare findings with conventional incident-reporting systems.

Methods

A two-stage structured retrospective record review of no-harm incidents was performed on a random sample of 350 admissions at a Swedish orthopedic department. Results were compared with those found in one local, and four national incident-reporting systems.

Results

We identified 118 no-harm incidents in 91 (26.0%) of the 350 records by retrospective record review. Ninety-four (79.7%) no-harm incidents were classified as preventable. The five incident-reporting systems identified 16 no-harm incidents, of which ten were also found by retrospective record review. The most common no-harm incidents were related to drug therapy (n = 66), of which 87.9% were regarded as preventable.

Conclusions

No-harm incidents are common and often preventable. Retrospective record review seems to be a valuable tool for identifying and characterizing no-harm incidents. Both harm and no-harm incidents can be identified in parallel during the same record review. By adding a retrospective record review of randomly selected records to conventional incident-reporting, health care providers can gain a clearer and broader picture of commonly occurring, no-harm incidents in order to improve patient safety.