Accidents in "normal" operation - Can you see them coming?

Journal of Loss Prevention in the Process Industries

Volumn 23, Issue 2, 2010, Pages 351-366

  Sonnemans, P J M ^b   Korvers P M W ^a   Pasman, H J ^c  

^a SABIC Europe   (Netherlands)

^b EINDHOVEN UNIVERSITY OF TECHNOLOGY   (Netherlands)

^c DELFT UNIVERSITY OF TECHNOLOGY   (Netherlands)

Author keywords

Accident prevention; Analysis protocol; Precursor; Process safety; Resilient engineering; Risk

Indexed keywords

ANALYSIS PROTOCOL; CHEMICAL PROCESS INDUSTRY; CONTROL PROCESS; CONTROL STRUCTURE; HIGHER EFFICIENCY; PRECURSOR; PROCESS SAFETY; SAFETY BARRIERS; SAFETY MEASURES; SAFETY RISKS;

ACCIDENT PREVENTION; ACCIDENTS; CHEMICAL INDUSTRY; INDICATORS (CHEMICAL); OCCUPATIONAL RISKS;

PROCESS CONTROL;

EID: 76149119068     PISSN: 09504230     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.jlp.2010.01.001     Document Type: Article

References (42)

1. Amelsvoort van P. Een model voor de moderne besturingsstructuur volgens de sociotechnische theorie. Gedrag en Organisatie 2 4/5 (1989) 253-267 (in Dutch)
2. Argyris C., and Schön D.A. Organizational learning II; theory, method, and practice (1996), Addison-Wesley, Amsterdam
3. Balasubramanian A., Kevrekedis K., Sonnemans P.J.M., and Newby M.J. Identifying factors influencing reliability of professional systems. Proceedings of the annual reliability and maintainability symposium (2008), RAMS, IEEE Inc., Las Vegas. 978-1-4244-1460-4 64-69 ISSN: 0149-144X
4. Bateson G. Steps to an ecology of mind (1972), Ballantine Books, New York
5. Bickman L., and Rog D.J. Handbook of applied social research methods (1998), Sage Publications, London
6. Boreham N.C., Shea C.E., and Mackway-Jones K. Clinical risk and collective competence in the hospital emergency department in the UK. Social Science and Medicine 51 (2000) 83-91
7. BRZO (1999). Besluit Risico's Zware Ongevallen, Staatsblad van het Koninkrijk der Nederlanden 1999, 234 (in Dutch).
8. Busby J.S., and Hughes E.J. The role of distributed cognition in the causation of accidents. International Journal of Risk Assessment and Management 4 1 (2003) 36-51
9. Center for Chemical Process Safety/AIChE. Guidelines for process safety metrics (2009), Wiley, N.Y. 978-0-470-57212-2
10. Dekker S. The field guide to human error investigations. 1st ed. (2002), Ashgate Publ., Aldershot
11. Falster P. Describing production situations. In: Wortmann J.C., Muntslag D.R., and Timmermans P.J.M. (Eds). Customer driven manufacturing (1997), Chapmann & Hall, London
12. Geudens W.H.J., Sonnemans P.J.M., Brombacher A.C., and Petkova V.T. Soft reliability, a new class of problems for innovative products: how to approach them. Proceedings of the annual reliability and maintainability symposium, 0149-144X (24-27 January 2005), RAMS, IEEE Inc., Alexandria, Virginia 374-378
13. Hale A., Baram M., and Hovden J. Perspectives on safety management and change. In: Hale A., and Baram M. (Eds). Safety management. The challenge of organisational change (1998), Pergamon, Oxford 1-15
14. In: Hollnagel E., Woods D.D., and Leveson N. (Eds). Resilience engineering, concepts and precepts (2006), Ashgate Publ. Ltd., Aldershot, U.K. 0-7546-4641-6
15. Houben M.J.H.A., Sonnemans P.J.M., and Newby M.J. Uncertainty in reliability estimation: when do we know everything we know?. In: Bris R., Guedes Soares C., and Martorell S. (Eds). Reliability, risk and safety: Theory and applications (2009), Taylor & Francis group, London. 978-0-415-55509-8 61-64
16. Hudson, P. T. W., Parker, D., & van der Graaf, G. C. (2002) The Hearts and Minds Program: Understanding HSE culture. In Proceedings of the 6th SPE international conference on health safety and environment in oil and gas exploration and production. Richardson, TX: Society of Petroleum Engineers, see also www.energyinst.org.uk/heartsandminds/.
17. Hudson, P. T. W., Wagenaar, W. A., Reason, J. T., Groeneweg, J., Meeren van der, R. W., & Visser, J. P. (1991). Enhancing safety in drilling: Implementing TRIPOD in a desert drilling operation. SPE Paper 23248 First International Conference on Health, Safety, and Environment, The Hague.
18. Jacobs R., and Haber S. Organizational processes and nuclear power plant safety. Reliability Engineering and System Safety 45 (1994) 75-83
19. Johnson W.G. MORT (1980), Safety Assurance System, National Safety Council and Marcel Dekker Inc., New York
20. Keuning D. Organiseren en leidinggeven. 3rd ed. (1991), Stenfert Kroese, Leiden
21. Körvers, P. M. W. (2004). Accident precursors: pro-active identification of safety risks in the chemical process industry. PhD-thesis, Technische Universiteit Eindhoven, Eindhoven.
22. Körvers P.M.W., and Sonnemans P.J.M. Accidents: a discrepancy between indicators and FACTS. Safety Science 46 (2008), Elsevier Ltd. 1067-1077
23. Marono M., Correa M.A., and Sola R. Strategy for the development of operational safety indicators in the chemical industry. Proceedings of the 9th international symposium on loss prevention and safety promotion in the process industries (1998), Elsevier Science BV, Barcelona 205-215
24. Øien K. A framework for the establishment of organizational risk indicators. Reliability Engineering and System Safety 74 (2001) 147-167
25. Perrow C. Normal accidents (1984), Basic Books, New York
26. Rasmussen J. Risk management in a dynamic society: a modelling problem. Safety Science 27 2/3 (1997) 183-213
27. Reason J. Managing the risks of organizational accidents (1997), Ashgate Publ., Aldershot
28. Schaaf van der T.W. A framework for designing near miss management systems. In: van der Schaaf T.W., Lucas D.A., and Hale A.R. (Eds). Near miss reporting as a safety tool (1991), Butterworth Heinemann, Oxford
29. Schaaf van der, T. W. (1992). Near miss reporting in the chemical process industry. PhD thesis, Eindhoven University of Technology, Eindhoven.
30. Schein E.H. Process consultation revisited: Building the helping relationship (1999), Addison Wesley, Amsterdam
31. Sitter de L.U. Op weg naar nieuwe fabrieken en kantoren. 5th ed. (in Dutch) (1987), Kluwer, Deventer
32. Sonnemans P.J.M., Balasubramanian A., Kevrekedis K., and Newby M.J. A method to efficiently represent diverse field usage in reliability testing of professional systems. Proceedings of the annual reliability and maintainability symposium (2008), RAMS, IEEE Inc., Las Vegas. 978-1-4244-1460-4 132-136 ISSN: 0149-144X
33. Sonnemans P.J.M., and Körvers P.M.W. Accidents in chemical industry: are they foreseeable?. Journal of Loss Prevention in the Process Industries, 0950-4230 19 1 (2006) 1-12 Elsevier Ltd.
34. Sonnemans P.J.M., Körvers P.M.W., Brombacher A.C., Beek van P.C., and Reinders J.E.A. Accidents the result of uncontrolled business process. Quality and Reliability Engineering International 19 3 (2003) 183-196
35. Sorensen J.N. Safety culture: a survey of the state-of-the-art. Reliability Engineering and System Safety 76 (2002) 189-204
36. Steen van J. Safety performance measurement, European process safety centre (1996), Bookcraft Ltd., Somerset
37. Suokas J., and Rouhiainen V. Quality management of safety and risk analysis (1993), Elsevier, Amsterdam
38. Svenson P. Accident and incident analysis based on the accident evaluation and barrier function (AEB) model. Cognition, Technology and Work 3 (2001) 42-52
39. Tixier J., Dusserre G., Salvi O., and Gaston D. Review of 62 risk analysis methodologies of industrial plants. Journal of Loss Prevention in the Process Industries 15 (2002) 291-303
40. Veld in het J. Analyse van organisatieproblemen - een toepassing van denken in systemen en processen. 7th ed. (in Dutch) (1999), Educatieve Partners Nederland BV, Houten
41. Weil, R., Apostolakis, G. (1999). Identification of important organizational factors using operating experience. In Proceedings of the 3rd international conference on human factor research in nuclear power operations, Japan.
42. Yin R.K. Case study research: Design and methods. 2nd ed. (1994), Sage Publications, London