American Society of Safety Engineers – Middle East Chapter (ASSE-MEC) 9th Professional Development Conference & Exhibition (PDC&E) February 20-24, 2010 Kingdom of Bahrain The study of near misses and the knowledge management in mature industries Patrizia Agnello, Silvia Ansaldi, Paolo A. Bragatto, Paolo Pittiglio ISPESL - Italian Institute for Occupational Safety and Prevention Via Fontana Candida 1 – Monteporzio Catone (Roma) – 00040 Italy Contact author: [email_address]
ACCIDENTS CONTINUE TO HAPPEN !
In mature industries every technical issue has been already studied and understood, The knowledge that is stored inside the safety documents is huge indeed …. but unfortunately accidents continue to happen!!
In mature industries the knowledge underlying all the activities, is assumed perfectly defined and formalized. Accidents happen not for lack of knowledge, but because it has been ignored, or forgotten, or distorted, or badly applied by the operators.
A near miss that happens inside an industrial facility is a challenge for the complex knowledge system, which rules all the activities.
There is a huge knowledge about safety, “sleeping” in dust covered documents. The study of near-misses has the potential to “wake up” individual pieces of knowledge and make them really useful for operators.
Scope: Mature Industries , where accidents happen not for lack of knowledge, but because it has been ignored, or forgotten, or distorted, or badly applied by the operators.
Section 1 the internal proprietary Knowledge
=> A digital model of the internal safety management, including equipment and procedures
=> From a near-miss may start a walk trough thr safety model, to retireve the speeping knowledge in internal documents (procedures, reports)
Section 2 The external shared Knowledge
=> The external regulatory system as knowledge repository.
=> The methodology for finding the sleeping knowledge in external documents, including regulations, codes, safety alert, technical papers
In this paper a wider meaning for word “near miss” has been assumed, in order to include every non conforming events, as they have the potential to forerun accidents.
In such a way even latent conditions, which might lead to an accident after a long time, may be early detected
the case studies of the research are restricted to the facilities where major accident legislation is enforced. (All are mature industry)
The European legislation on major accident hazard, ( SEVESO or COMAH ), defines a framework, which structures the safety system along the lifecycle of the plant, including hazard identification and risk analysis, safety policy and management, operational procedures, emergency management and periodical safety audit.
near-misses analysis is a part of the safety management system.
Regulatory Inspections Penalties Internal Audits Control Sanctioned by Authorities or by Experts Committees Internal Approval by the duty-holder Ratification Weak, Layered, Not conflicting each-other Strong, Hierarchical Structure (reciprocal links among single rules in the system) Experience Based, Prescriptive Risk Based, Deductive Based on- An entire industry A single firm Scope 10 years or more 1 year or less Life cycle (typical revision time) Public Domain Proprietary / Internal Ownership of the Knowledge Safety Regulatory System Safety Management System
A DUAL SYSTEM
As the internal safety management system and the external safety regulation system are definitely different, the problem of finding and reviving the knowledge about safety has been divided in two separate issues:
i) Retrieve knowledge by walking trough the Safety Management System (including Safety assessment) of the single firm.
ii) Retrieve knowledge by browsing in the public Regulation system, in the technical documentation, and in the experience repository.
Section 1 The Knowledge Inside the Establishment
NOCE (NO_Conforming Events) a proprietary software.
The system starts from the mandatory documents and looks for the knowledge which may be relevant to the near miss and to the item involved.
the analysis of the event on the light of the safety documentation;
if the event is linked to a chain leading to a top event, it will be noticed.
If the component, which the event is related to, has not direct link to the safety documents, its parent assembly or unit will be considered.
Safety digital representation
Equipment digital representation + Digital safety documents + link
Equipment digital representation is the backbone of the system.
Plant scrutiny, according the Mond Idex may be exploited.
List of top events Event Risk assessment Accidental sequence unit Facility Accessory Mond Index Penality Credit Component Risk Management Emergency Plan Emergency Action
Safety Mgmnt System List of top events Event Safety Report Accidental sequence Emergency Plan Emergency Action Inspection Plan Inspection OperatingManual Operating Procedure Action unit Facility Accessory Mond Index Penality Credit Component
List of top events Event Risk assessment Accidental sequence Emergency Plan OperatingManual Inspection Plan Emergency Action Operating Procedure Risk Management Inspection Action unit Facility Accessory Mond Index Penality Credit Component
NOCE exploits the “plant safety” digital representation, for:
reporting and analyzing near-misses.
Updating safety documents, according to the operational experience.
For the digital equipment representation, no extra duties are required; but safety documents have to be exploited in a smarter way.
Section 2 The vs. Knowledge on Demand
The formal knowledge is mainly unstructured. It is distributed in technical - regulatory documents,
Which include regulations, standard codes, guidelines, good practices, manufacturers manuals, safety alerts,
Organizing these documents is too difficult job for an individual firm. It is a job for an industrial association (or consortium or occupational safety and health agencies)
Taxonomy vs Ontology
A taxonomy is able only to give a location to each document.
An analytical decomposition and a synthetic recomposition of any item are always possible using an “ontology”,
A ontology provide a schema to put tags in the documents and to retrieve them trough a search engine.
The ontology of the “safety measures”
firefitghting PPE materials processes activities procedures instruments equipment firefigthing PPE materials processes activities procedures instruments equipment
The search is done through the concept which associates the substance ( e.g. fuming sulphuric acid ) and the event ( corrosion ). Many affecting issues may be found, but the operator evaluates which one is appropriate to the case. In the example, the critical factor considered has been the presence of humidity, which accelerates the corrosion. Detailing the problem has the advantage to focus the search to find solutions through a few concepts. In the example, the search query is reduced to look for “ how to remove the cause humidity ”, and then which technical measure can be adopted.
That specific solution represents a sleeping knowledge, since it is a solution already available, but not yet considered inside the establishment.
NOCE is a software for finding the knowledge hidden in the internal documents. It may be used by duty holders. It requires two items:
a safety management system structured according to a defined standard (e.g. BS 18001/2007)
a digital representation of the plant equipment.
The analysis has been developed for the establishments where the Major Accident Legislation is enforced.
The solution, could be transferred to the establishments where Major Accident Hazard Legislation is not enforced, but where a safety management system, including an adequate risk evaluation, is present.
The presented version of the engine for finding the knowledge hidden in the public documents has been developed for the ISPESL local network (featuring some forty departements and offices, spraded in Italy)
The proposed method, is adequate to be implemented by an industrial associations, or by an industrial consortium, or by a corporate.
The study of near misses and the knowledge management in mature industries Patrizia Agnello, Silvia Ansaldi, Paolo A. Bragatto, Paolo Pittiglio ISPESL - Italian Institute for Occupational Safety and Prevention Via Fontana Candida 1 – Monteporzio Catone (Roma) – 00040 Italy Contact author: [email_address] Thanks for your attention! Grazie!