Unsafe acts and unsafe outcomes in aircraft maintenance

Road safety studies using the Driver Behaviour Questionnaire (DBQ) have provided support for a three-way distinction between violations, skill-based errors and mistakes, and have indicated that a tendency to commit driving violations is associated with an increased risk of accident involvement. The aims of this study were to examine whether the three-way distinction of unsafe acts is applicable in the context of aircraft maintenance, and whether involvement in maintenance safety occurrences can be predicted on the basis of self-reported unsafe acts. A Maintenance Behaviour Questionnaire (MBQ) was developed to explore patterns of unsafe acts committed by aircraft maintenance mechanics. The MBQ was completed anonymously by over 1300 Australian aviation mechanics, who also provided information on their involvement in workplace accidents and incidents. Four factors were identified: routine violations, skill-based errors, mistakes and exceptional violations. Violations and mistakes were related significantly to the occurrence of incidents that jeopardized the quality of aircraft maintenance, but were not related to workplace injuries. Skill-based errors, while not related to work quality incidents, were related to workplace injuries. The results are consistent with the three-way typology of unsafe acts described by Reason et al. (1990) and with the DBQ research indicating an association between self-reported violations and accidents. The current findings suggest that interventions addressed at maintenance quality incidents should take into account the role of violations and mistakes, and the factors that promote them. In contrast, interventions directed at reducing workplace injury are likely to require a focus on skill-based errors.     

Unsafe acts and unsafe outcomes in aircraft maintenance

Road safety studies using the Driver Behaviour Questionnaire (DBQ) have provided support for a three-way distinction between violations, skill-based errors and mistakes, and have indicated that a tendency to commit driving violations is associated with an increased risk of accident involvement. The aims of this study were to examine whether the three-way distinction of unsafe acts is applicable in the context of aircraft maintenance, and whether involvement in maintenance safety occurrences can be predicted on the basis of self-reported unsafe acts. A Maintenance Behaviour Questionnaire (MBQ) was developed to explore patterns of unsafe acts committed by aircraft maintenance mechanics. The MBQ was completed anonymously by over 1300 Australian aviation mechanics, who also provided information on their involvement in workplace accidents and incidents. Four factors were identified: routine violations, skill-based errors, mistakes and exceptional violations. Violations and mistakes were related significantly to the occurrence of incidents that jeopardized the quality of aircraft maintenance, but were not related to workplace injuries. Skill-based errors, while not related to work quality incidents, were related to workplace injuries. The results are consistent with the three-way typology of unsafe acts described by Reason et al. (1990) and with the DBQ research indicating an association between self-reported violations and accidents. The current findings suggest that interventions addressed at maintenance quality incidents should take into account the role of violations and mistakes, and the factors that promote them. In contrast, interventions directed at reducing workplace injury are likely to require a focus on skill-based errors.     

The influence of employee training and information on the probability of accident rates

The construction industry is one of the most important socio-economic sectors of the Spanish economy and one of the most affected by workplace accidents. An analysis of the data on accident rates is needed, in order to identify variables related with workplace accidents and to define the measures that need to be taken for their reduction. In this study, an analysis is conducted using Bayesian Networks and data from the 7th National Survey on Working Conditions (VII NSWC), to study the relations between workplace accidents, visiting a doctor for occupational reasons, time in the company/sector, information that workers have on workplace risks in the workplace, and information and training on workplace risks that workers have received over the past two years. The NSWC survey, which is conducted every four years, was administered to 8892 workers, in Spain, in 2011. The values derived from the analysis yield certain implications involving the aforementioned variables and how to reduce the probability of workplace accidents. From among the variables under study, information on workplace risks is the most important, with the probability of suffering an accident in the construction industry doubling when such information is insufficient. In accordance with the results, these implications could also help with decision-making focused on improvements to training and on-the-job information, intended both to prevent and to reduce workplace accidents.     

Contributing factors in construction accidents

This overview paper draws together findings from previous focus group research and studies of 100 individual construction accidents. Pursuing issues raised by the focus groups, the accident studies collected qualitative information on the circumstances of each incident and the causal influences involved. Site based data collection entailed interviews with accident-involved personnel and their supervisor or manager, inspection of the accident location, and review of appropriate documentation. Relevant issues from the site investigations were then followed up with off-site stakeholders, including designers, manufacturers and suppliers. Levels of involvement of key factors in the accidents were: problems arising from workers or the work team (70% of accidents), workplace issues (49%), shortcomings with equipment (including PPE) (56%), problems with suitability and condition of materials (27%), and deficiencies with risk management (84%). Employing an ergonomics systems approach, a model is proposed, indicating the manner in which originating managerial, design and cultural factors shape the circumstances found in the work place, giving rise to the acts and conditions which, in turn, lead to accidents. It is argued that attention to the originating influences will be necessary for sustained improvement in construction safety to be achieved.     

Zeitschrift für Arbeitswissenschaft Abstracts of papers,Vol. 42 (14 NF), Part 1, 1988

This study sought to identify causal factors for slip, trip and fall accidents occurring during the delivery of mail. Analysis of in-house data produced information about accident circumstances for 1734 fall cases. The most common initiating events in delivery falls were slips and trips. Slips most often occurred on snow, ice or grass, while trips tended to involve uneven pavements, obstacles and kerbs. Nearly one-fifth of falls occurred on steps, with step falls requiring longer absence from work than falls on the level. Half of all falls occurred during November-February and three-quarters of falls occurred between 7 and 9 a.m. Incidence rates for female employees were 50% higher than for their male colleagues. Accident-independent methods included interviews with safety personnel and managers, discussion groups with delivery employees, and a questionnaire survey of employees and managers. These techniques provided data on risk factors related to the task, behaviour, footwear and equipment. Arising from these accident-independent investigations, it is suggested that unsafe working practices, such as reading addresses while walking and taking shortcuts, increase the risk of falls. Organizational issues include management safety activities, training and equipment provision. Measures are discussed that might lead to a reduction in the incidence of delivery fall accidents.     

Investigating interactions among vital variables affecting situation awareness based on Fuzzy DEMATEL method

In many accident reports, failure in situation awareness is mentioned as one of the immediate causes of those accidents. Accordingly, the identification of variables affecting situation awareness and their interactions are key factors in preventing accidents. This study aims to identify interactions among the most important individual, situational, and organizational variables affecting situation awareness in industrial workplaces. Using Fuzzy Delphi and Fuzzy DEMATEL methods, this study was conducted based on the data collected from experts’ judgments. The results show that organizational variables and some individual variables are the critical factors affecting situation awareness, and their effect is directly or indirectly created by situational and individual variables. The results of the study can be used to design proper guidelines for industry managers and employers to improve safety performance in the workplace; in addition, the findings of the study can be employed to design future studies to model the predictive power of variables affecting situation awareness in different work environments.     

Associations between errors and contributing factors in aircraft maintenance

In recent years cognitive error models have provided insights into the unsafe acts that lead to many accidents in safety-critical environments. Most models of accident causation are based on the notion that human errors occur in the context of contributing factors. However, there is a lack of published information on possible links between specific errors and contributing factors. A total of 619 safety occurrences involving aircraft maintenance were reported using a self-completed questionnaire. Of these occurrences, 96% were related to the actions of maintenance personnel. The types of errors that were involved, and the contributing factors associated with those actions, were determined. Each type of error was associated with a particular set of contributing factors and with specific occurrence outcomes. Among the associations were links between memory lapses and fatigue and between rule violations and time pressure. Potential applications of this research include assisting with the design of accident prevention strategies, the estimation of human error probabilities, and the monitoring of organizational safety performance.     

The role of psychological factors in workplace safety

Workplace safety researchers and practitioners generally agree that it is necessary to understand the psychological factors that influence people's workplace safety behaviour. Yet, the search for reliable individual differences regarding psychological factors associated with workplace safety has lead to sparse results and inconclusive findings. The aim of this study was to investigate whether there are differences between the psychological factors, cognitive ability, personality and work-wellness of employees involved in workplace incidents and accidents and/or driver vehicle accidents and those who are not. The study population (N = 279) consisted of employees employed at an electricity supply organisation in South Africa. Mann–Whitney U-test and one-way ANOVA were conducted to determine the differences in the respective psychological factors between the groups. These results showed that cognitive ability did not seem to play a role in workplace incident/accident involvement, including driver vehicle accidents, while the wellness factors burnout and sense of coherence, as well as certain personality traits, namely conscientiousness, pragmatic and gregariousness play a statistically significant role in individuals' involvement in workplace incidents/accidents/driver vehicle accidents. Safety practitioners, managers and human resource specialists should take cognisance of the role of specifically work-wellness in workplace safety behaviour, as management can influence these negative states that are often caused by continuously stressful situations, and subsequently enhance work place safety.     

A systems approach to organizational error

Abstract

The past two decades have seen a significant number of large-scale disasters in a wide range of hazardous, well-defended technologies. Despite their differences, the root causes of these accidents have been traced to latent failures and organizational errors arising in the upper echelons of the system in question. A model of the aetiology of these organizational accidents is outlined. The model describes two interrelated causal sequences: (a) an active failure pathway that originates in top-level decisions and proceeds via error-producing and violation-promoting conditions in the various workplaces to unsafe acts committed by those at the immediate human-system interface and (b) a latent failure pathway that runs directly from the organizational processes to deficiencies in the system's defences. The paper goes on to identify two sets of dependencies associated with latent failures and violations. Organizational errors increase the likelihood of operator error through the active failure pathway and, at the same time, enhance the possibility of adverse outcomes through defensive weaknesses. Violations have a narrower range of consequences. Non-compliance with safe operating procedures increases the likelihood of error by taking perpetrators into regions of operation in which neither the physical regime nor the hazards are well understood. Violations, by definition, also take perpetrators ‘closer to the edge,’ and thus increase the chance that subsequent errors will have damaging outcomes. The paper concludes by indicating two ways in which the model has been applied in industrial settings: (a) through the development of proactive measures for diagnosing and remedying organizational processes known to be implicated in accident causation, and (b) an accident investigation technique that guides investigators and analysts to the organizational root causes of past accidents.     

Quantifying and comparing the effects of human and organizational factors in electric maloperation accidents with HFACS–CatBoost and SHAP

The proportion of electric maloperation accidents (EMAs) in substations caused by human and organizational factors (HOFs) has gradually increased. Although there has been some research into the factors affecting EMAs in substations, the available results are insufficient to support the interpretation of HOFs in EMAs. This article explores the relationships between the HOFs and EMAs using Human Factors Analysis and Classification System-gradient boosting with categorical features support (HFACS–CatBoost) and Shapley Additive exPlanation (SHAP) methods. First, the HFACS framework was introduced to identify 135 EMAs in the Southern Power Grid risk causation. CatBoost was used to construct an accident classification model to analyze the important relationship between accidents and HOFs and to compare and analyze with the extreme gradient boosting (XGBoost) and the binary logistic regression (BLR) to verify the superiority of CatBoost. Finally, to solve the problem of inadequate interpretation of the CatBoost black-box model, the SHAP value plot was applied to express the contribution degree relationship between accidents and HOFs. The results show that the above method can explore and explain the importance and contribution of HOFs in EMAs. And from this, it is concluded that poor psychological state, poor communication and coordination, inadequate supervision, and inadequate training and education are highly correlated with the occurrence of EMAs. The findings will help substation operations and maintenance staff to develop safety measures to address the confusion of HOFs in substations and prevent the occurrence of EMAs.     

Industrial accidents are produced by social relations of work: a sociological theory of industrial accidents

Industrial accidents are produced by social relations work. This sociological explanation of accidents differs from the hypotheses on which the majority of modern safety practices are based, which reduce accident causes to unsafe acts and unsafe conditions. Accidents are seen as produced at each of three levels of social relations of work (rewards, command and organisation), and also non-socially at the individual-member level. The resulting hypotheses were tested using data collected according to a semi-experimental design in seven plants in which shift (day/night), shift type (rotating/fixed), technological type and management styles were the factors controlled for. Because of the design, machines, materials and, in most cases, workers were the same across shifts and social relations varied. The sociological theory proved capable of explaining most of the variation in inter-shift differences in accident rates, and, when tested statistically, appeared to have greater explanatory power than competing hypotheses. It is concluded that accidents can be prevented by workers who exercise auto-control at all levels and by management which, in the absence of worker orientations favourable to auto-control, engages in safety management as defined sociologically. A practical consequence for ergonomics is that when plant, equipment and processes are to be modified, an attempt to understand their interaction with the social relations of work should be made. A theoretical consequence is that sociological insights should be incorporated into the perspective of the ergonomics discipline.     

The Causes of Severe Accidents in the Andalusian Manufacturing Sector: The Role of Human Factors in Official Accident Investigations

This study examines the associations between worker characteristics and accident causation. It is based on the causes identified in the accidents investigated in the manufacturing sector of Andalusia (Spain) from 2004 to 2011 by the Labour Authority. The method used to assess the association between the categorical variables related to worker characteristics and types of causes is the phi coefficient test for each specific combination of categories of the variables. The main results are as follows. For young workers, the most likely causes include being assigned a task without the proper qualifications, using inappropriate work methods, and misunderstanding instructions. For low‐experience workers, the most likely cause is a lack of experience. For nonmanual qualified workers, the most likely causes include performing tasks without proper experience or personal protective equipment and performing nonroutine tasks. This differential causation found, depending on worker characteristics, can be used to design more effective preventive programs.     

Human Factor Analysis of JCO Criticality Accident

The criticality accident that occurred on September 30, 1999 at a uranium processing plant in Tokai-mura was an unprecedented nuclear accident in Japan, not only because it caused deaths of two workers due to radiation casualty but also because it called for evacuation and sheltering indoors to nearby residents. The accident was not directly caused by failures or malfunctions of hardware but by workers’ unsafe action deviated from the approved procedure. It was a typical organizational accident in that several organizational factors worked behind. This article is to analyze various causal factors that lead to the accident, including situational factors of workers’ unsafe action that triggered the accident, operational and business management of the company, and nuclear safety regulation by the government. It also discusses problems of emergency response after the accident.     

Privacy and biometrics: An empirical examination of employee concerns

Advances in authentication technology have led to a proliferation of biometric-based systems in the workplace. Although biometric technologies offer organizations a cost-effective method of increasing security, employees are often hesitant to permit use. The collection and storage of employee biometric data raises concerns about proper use of these intensely personal identifiers. This work draws from organizational privacy practices, electronic monitoring, procedural fairness, self-construal, and technology adoption theories. We investigate the effects of independent and interdependent self-construal on three newly developed dimensions of employee privacy concern related to organizational use of biometric technology. These dimensions include perceived accountability, perceived vulnerability, and perceived distrust toward the organization. We test the predictive power of our model using data from an organization deploying a new biometric system designed to track employee work assignments under the auspices of improving personnel safety. Results indicate that self-construal plays a significant role in the formulation of privacy concerns and both perceived accountability concerns and perceived vulnerability concerns are significant predictors of attitude toward using biometric technology in the workplace.     

Creating a performance-oriented e-learning environment: A design science approach

E-learning is now being used by many organizations as an approach for enhancing the skills of knowledge workers. However, most applications have performed poorly in motivating employee learning, being perceived as less effective due to a lack of alignment of learning with work performance. To help solve this problem, we developed a performance-oriented approach using design science research methods. It uses performance measurement to clarify organizational goals and individual learning needs and links them to e-learning applications. The key concept lies in a Key Performance Indicator model, where organizational mission and vision are translated into a set of targets that drive learning towards a goal of improving work performance. We explored the mechanisms needed to utilize our approach and examined the necessary conceptual framework and implementation details. To demonstrate the effectiveness of the approach, a prototype workplace e-learning system was developed and used to evaluate the effectiveness of our approach.     

Warnings: a supplement not a substitute for other approaches to safety

Warnings in the workplace are analysed from the global perspective that they are not a substitute for, but rather a supplement to, good product design, employee selection, training, job design, supervision, and the provision of other forms of safety information including written procedures and checklists. An explanation is given for when and why these latter approaches will be more effective for reducing both errors and violations. Situations where warnings will be useful and further areas of research are also discussed.     

Types and tokens in road accident causation

Accidents are preceded by long histories containing multitudes of events that constitute promising targets for preventive action. These antecedent events can be classified into at least four groups that occur in this order: failure types; psychological precursors; unsafe acts; and breakdown of defences. It is argued that events directly preceding an accident, such as breakdown of defences and unsafe acts, are only haphazard tokens of the more permanent weaknesses within a system, called failure types. Elimination of a type will therefore have much more impact than the elimination of one or a few tokens. It is also argued that there exist only a limited number of failure types, which are responsible for all accidents. However, in the specific area of road accidents, it is not known which types cause most of the problems. Therefore, their relative importance can only be guessed. We guessed that hardware problems and maintenance are unimportant types; that education and regulations are of moderate importance; and that incompatible goals, conditions promoting unsafe behaviour, and organizational inadequacy are the types that cause most of the accidents. The latter therefore constitute the most promising targets for accident prevention.     

The effects of organizational learning environment factors on e-learning acceptance

Workplace learning is an important means of employees’ continuous learning and professional development. E-learning is being recognized as an important supportive practice for learning at work. Current research on the success factors of e-learning in the workplace has emphasized on employees’ characteristics, technological attributes, and training design elements, with little attention to workplace contextual effects. The study aims to investigate the impacts of organizational learning environment factors, including managerial support, job support, and organizational support, on employees’ motivation to use a workplace e-learning system. A model was proposed based on the expectancy theory of training motivation and the social influences and facilitating conditions in technology acceptance models. The model was tested on sample data collected from mainland China using Structural Equation Modeling and Moderated Structural Equation Modeling. The results suggested that employees’ perceived managerial support and job support had a significant impact on their perceived usefulness of the e-learning system for individual learning, and that perceived organizational support had a significant influence on the perceived usefulness of the e-learning system for social learning. Perceived usefulness for individual learning was found to completely mediate the environmental influences on individuals’ motivation to use the system, while perceived usefulness for social learning made partial mediation in the effects of the environmental factors on intention to use. In addition, perceived job support was found to have moderating effects on the relationship between employees’ perceived usefulness of the e-learning system and their intention to use the system. Consistent with previous findings, employees’ perceptions about the usefulness of the e-learning system have significant effects on their intention to use the system in the work setting.     

Analysis of fire and explosion accidents occurring in tankers transporting hazardous cargoes

This study investigates maritime accident reports regarding fire and explosion (F&E) events that occurred between 1999 and 2013 in tankers transporting hazardous liquid cargoes. The aim is to analyse the root causes of F&E accidents and identify the relationship with their causative factors. The most significant causes of F&E accidents are found to be hot work, electric arcs, static electricity, and combustible gas accumulation in the cargo tank. The main causative factors are the violation of work permits and a lack of risk analysis. Fire prevention aboard ships can be improved by enhancing training standards and safety awareness, and reducing the commercial pressures on ship operations.     

基于状态向量的危化品事故分析方法及应用

危险化学品行业属于高危险性行业,各类爆炸、火灾、泄漏和中毒事故时有发生.传统的基于因果关系的事故链分析方法受限于传统安全工程所依赖的技术基础和假定无法适应于今天所建造的复杂系统.本文以事故致因理论为基础,分析危化品事故形成的主要影响因素,构建了危化品事故状态向量,全面描述导致危化品事故发生的因素,并基于构建的状态向量进行危化品事故分析预测应用.利用高维向量对事故状态进行了定义,尽最大可能考虑了造成事故发生的众多因素,并利用支持向量机学习算法,建立事故预测模型.对已掌握的危化品事故进行的样本实验表明,本文提出的危化品事故预测方法,可有效快速的甄别事故状态,对危化品行业事故的预测预防具有积极意义.