Rtb wkplace health, safety & risk 2010 v f 01 12-10
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10. Basic steps in risk assessment Classify work activities Identify hazards Determine risk Decide if risk is tolerable Prepare risk control action plan Review adequacy of action plan
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22. Traditional Safety Management ACCIDENT Investigate accident - steered by the preconceptions of the investigator Attribute primary cause to unsafe acts Attribute primary cause to unsafe conditions RULE devised forbidding unsafe acts TECHNICAL solution to make conditions safe
26. Time Perception of risk Serious accident Perceptions of risk and prevention
27. Time Perception of risk Serious accident Rules and safeguards devised here may be violated when perceptions decay over time Perceptions of risk and prevention
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29. Events and Outcomes ws Near miss Hazard Fatality Property damage Major injury Minor injury Event Accident Incident OUTCOME Environmental damage
31. Hale and Hale Model – behaviour in the face of danger Action Presented Information Expected Information Perceived Information Possible Actions Cost / Benefit Decision
32. Human Failure Knowledge- based Rule-based Lapses Slips Exceptional Skill-based (unintended) Errors Situational Mistakes (intended action * ) Routine Violations (intended) * But unintended diagnostic error Reason’s error type classification - ve Safety Culture
41. Reactive to Proactive - Safety Improvement Stages Risk Indicators Time & Effort Safety Culture Regulation Lead Management Lead People Lead
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55. Basic steps in risk assessment Classify work activities Identify hazards Determine risk Decide if risk is tolerable Prepare risk control action plan Review adequacy of action plan
66. Risk-based control plan RISK LEVEL ACTION (AND TIMESCALE) TRIVIAL No action, no records TOLERABLE No further action necessary: monitor to ensure controls maintained MODERATE Efforts to reduce risk, but costs of prevention should be limited SUBSTANTIAL Urgent efforts to reduce risk: reduction costs may be high INTOLERABLE Work should not be started or continued until risk reduced: no cost constraints for prevention
83. Steps in advanced risk assessment Cost-Benefit Analysis DEFINE SYSTEM IDENTIFY HAZARDS HAZARDOUS EVENTS HAZARDS EVENTS CONTINUING HAZARDS ANALYSE CONSEQUENCES DECIDE RISK CONTROL STRATEGY VERIFY ESTIMATE/ MEASURE RISKS EVALUATE RISKS NO CHANGE (MONITOR) YES NO IS RISK TOLERABLE? Task-based approach HAZOPS FMEA CHECK-LIST Event Tree Analysis Fault Tree Analysis Event Tree Analysis C Hierarchy Risk Matrix or Risk Calculator 1 in 10 ,000 1 in 1m QRA
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89. Principle of HAZOPS INTENTION DEVIATIONS Possible Causes Potential Consequences
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92. NO MORE LESS OTHER THAN GUIDE WORDS Principle of HAZOPS INTENTION DEVIATIONS Possible Causes Potential Consequences Inductive logic Deductive logic
100. Divide system into lines & tanks Local Extract Ventilation Design intention: to provide constant face velocity 5m/sec Fan Filters Face velocity 5 m/sec
101. No Flow Power fails Increased None A Consider emergency concentration power supply
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103. HAZOP WORK-SHEET Storage tank T-1 To store flammable reagent at 1.1 bar and 20° C G UIDE W ORD PROPERTY P OSSIBLE C AUSES C ONSEQUENCES A CTION R EQUIRED MORE LEVEL 1. Pump P-1 fails to stop Reagent released Incorporate high level alarm and trip 2. Reverse from process Reagent released Consider check valve Line 2 LESS 3. Pump P-1 cavitates Damage to P-1 Can reagent explode? If pump overheats? 4. Rupture in Line 2 Reagent released Consider alarm and pump shut-down 5. V-3 open Reagent released Consider alarm 6. V-1 open Same Same 7. Tank rupture Same What external events can cause rupture? NO Same as LESS OTHER THAN COM – 8.Wrong reagent Possible reaction Is reagent sampled before POSITION pumping ? AS WELL AS 9.Impu rity in reagent Possible overpressure, if What are the possible volatile impurities? LESS PRESSURE 10. Break in flare or Reagent released Consider low pressure alarm nitrogen lines 11. Loss of nitrogen Tank implodes What i s design vacuum of tank ? 12. CV-2 fails closed Tank implodes 13. PIC fails Tank implodes MORE 14. PIC fails Reagent released via R.valve What is capacity of CV-1 R. valve? 15. CV-1 fails closed Reagent released via Relief 16. V-7 c losed Same as (15) Is V-7 locked open? 17. Overfill tank See (6) Is V-8 locked open?
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105. Steps in advanced risk assessment Cost-Benefit Analysis DEFINE SYSTEM IDENTIFY HAZARDS HAZARDOUS EVENTS HAZARDS EVENTS CONTINUING HAZARDS ANALYSE CONSEQUENCES DECIDE RISK CONTROL STRATEGY VERIFY ESTIMATE/ MEASURE RISKS EVALUATE RISKS NO CHANGE (MONITOR) YES NO IS RISK TOLERABLE? Task-based approach HAZOPS FMEA CHECK-LIST Event Tree Analysis Fault Tree Analysis Event Tree Analysis C Hierarchy Risk Matrix or Risk Calculator 1 in 10 ,000 1 in 1m QRA
110. Details of pressure switch design Pressure Bellows Micro-switch Pivot Spring Beam PRESSURE SWITCH Pressure switch Storage tank Relay Pump Valve PT
111. Details of the transmitter design: Normally Open relay Pressure switch Storage tank Relay Pump Valve PT
112. FMEA: estimation and evaluation of risks A B C D E I II III IV Probability level Medium Medium risk risk High risk High risk RP1 RP1 RP3 RP3 Low risk Low risk RP2 RP2 Medium Medium risk risk Severity Category A B C D E Probability level 10 -1 10 -2 10 -3 10 -4 10 -5 Description I II III IV Severity category Minor Critical Major Catastrophic Degree Functional failure – minor injury/ ill health No major damage or serious injury Major damage and/or potential serious injury Complete system loss and/or potential fatality Description Probability value Frequent Probable Occasional Remote Improbable
115. FMEA: summary sheet Rank failure modes according to criticality; Decide actions required to reduce risks; Design measures should be considered as a priority
116. Normally open (NO) cam-activated electrical switch Guard Guard closed closed Guard Guard open open Hazard Hazard
117. Normally closed (NC) cam-activated electrical switch Guard Guard closed closed Guard Guard open open Hazard Hazard
120. Steps in advanced risk assessment Cost-Benefit Analysis DEFINE SYSTEM IDENTIFY HAZARDS HAZARDOUS EVENTS HAZARDS EVENTS CONTINUING HAZARDS ANALYSE CONSEQUENCES DECIDE RISK CONTROL STRATEGY VERIFY ESTIMATE/ MEASURE RISKS EVALUATE RISKS NO CHANGE (MONITOR) YES NO IS RISK TOLERABLE? Task-based approach HAZOPS FMEA CHECK-LIST Event Tree Analysis Fault Tree Analysis Event Tree Analysis C Hierarchy Risk Matrix or Risk Calculator 1 in 10 ,000 1 in 1m QRA
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123. “ FIRE” “ FIRE” Fails Fails Success Major Major Fire A A B B C C D D E E Initiating event Detector Valve Water supply Success Success Alarm Major fire Major fire Possible fatalities Possible fatalities Sprinkler might Sprinkler might work work Evacuation of Evacuation of personnel personnel No sprinkler No sprinkler protection protection
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125. “ FIRE” “ FIRE” Fails Fails Success P = 0.1 P = 0.1 P = 0.90 P = 0.05 P = 0.05 P = 0.95 P = 0.9 P = 0.1 P = 0.1 P = 0.95 P = 0.05 P = 0.05 P=0.731 Evacuation of Evacuation of personnel personnel No sprinkler No sprinkler protection protection P=0.1 Major fire Possible fatalities Sprinkler might work Major Fire A A B B C C D D E E Initiating Event Detector Valve Water supply Success Success Alarm
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127. Major fire Possible fatalities Sprinkler might work Major Fire Initiating Event Detector Valve Water sprinkler Alarm ƒ = 0.1/yr ƒ = 0.0731 /yr ƒ = 0.01/yr “ FIRE” “ FIRE” Fails Fails Success P = 0.1 P = 0.1 P = 0.90 P = 0.05 P = 0.05 P = 0.95 P = 0.9 P = 0.1 P = 0.1 P = 0.95 P = 0.05 P = 0.05 Evacuation of Evacuation of personnel personnel No sprinkler No sprinkler protection protection A A B B C C D D E E Success Success
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129. Steps in advanced risk assessment Cost-Benefit Analysis DEFINE SYSTEM IDENTIFY HAZARDS HAZARDOUS EVENTS HAZARDS EVENTS CONTINUING HAZARDS ANALYSE CONSEQUENCES DECIDE RISK CONTROL STRATEGY VERIFY ESTIMATE/ MEASURE RISKS EVALUATE RISKS NO CHANGE (MONITOR) YES NO IS RISK TOLERABLE? Task-based approach HAZOPS FMEA CHECK-LIST Event Tree Analysis Fault Tree Analysis Event Tree Analysis C Hierarchy Risk Matrix or Risk Calculator 1 in 10 ,000 1 in 1m QRA
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131. The ‘OR’ Gate ARRIVE LATE A WAKE UP LATE X DELAYED EN ROUTE Y INCORRECT TIME Z TOP EVENT (OUTPUT) INPUT EVENTS Event ‘A’ occurs if (at least) one of X OR Y OR Z occurs OR
133. FTA –lighting system Fuse Switch Bulb 1 Bulb 2 Power Source Room dark Power off Power supply failed Switch open Fuse Blown Both bulbs burned out Bulb 1 burned out Bulb 2 burned out
137. Human Error as a function of stress level Error Rate Stress Level Bored Over-excited
138. Hierarchical Task Analysis ‘HTA’ A process of developing a description of a task in terms of operations - things which people should do and plans - statements of conditions when each task/step has to be carried out
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143. Hierarchical Task Analysis ‘HTA’ 0 WIRE A THREE PIN PLUG 1 PREPARE PLUG 2 PREPARE CABLE 3 4 TEST PLUG 2.1 CUT & STRIP OUTER CABLE SHEATH 2.2 2.3 CARRY OUT ASSEMBLY 3.2 3.3 3.4 SELECT AND FIT 13 Amp FUSE 3.5 TIGHTEN CABLE STRIP & REPLACE COVER Plan 0: do in order Plan 2: 1 then 2 then 3 Plan 3: 1,2,3,4 then 5 CUT & STRIP INDIVIDUAL WIRES AS MARKED TERMINATE ALL 3 WIRE STRANDS 3.1 FIT BLUE WIRE IN TERMINAL 1 & TIGHTEN SCREW FIT YELLOW WIRE IN TERMINAL 2 & TIGHTEN SCREW FIT BROWN WIRE IN TERMINAL 3 & TIGHTEN SCREW
149. HSE ‘ALARP’ Intolerable Risk Upper Limit Lower Limit Negligible As Low As Reasonably Practicable ‘ALARP’ Broadly acceptable
150. HSE ‘ALARP’ Intolerable Risk Upper Limit: 1 in 1,000 (workers) 1 in 10,000 (public) Risk of death / year Lower Limit: 1 in a million (workers & public) Risk of death / year Negligible As Low As Reasonable Practicable ‘ALARP’ Broadly acceptable
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153. Death as an annual experience Cause of Death chance/year All causes Overall average 55-64 men women 35-44 men women 5-14 boys girls Hang gliding Road accidents Gas explosion (home) Electrocution (home) Lightning 1 in 87 1 in 65 1 in 110 1 in 578 1 in 873 1 in 4,400 1 in 6,250 1 in 670 1 in 10,200 1 in 1 million 1 in 1 million 1 in 10 million
154. Death as an annual experience Cause of Death chance/year Work Accidents deep sea fishing extraction oil / gas construction agriculture all manufacturing 1 in 750 1 in 990 1 in 10,200 1 in 13,500 1 in 53,000
155. Death as a consequence of an activity Activity Chance of death Travel for 100,000 km by motor bike by pedal cycle by car by rail by bus by air Balloon (Atlantic) Pregnancy Anaesthesia 1 in 100 1 in 200 1 in 2,200 1 in 9,000 1 in 22,000 1 in 44,000 1 in 3 1 in 13,000 1 in 25,000
156. Average loss of life expectancy as a consequence of an activity Cause Loss of Life Expectancy (days) Being unmarried (male) Smoker (male) Being unmarried (female) Smoker (female) Dangerous job Vehicle accidents Homicide Average job Medical X rays Coffee drinking Reactor accidents Nuclear industry Smoke alarm Mobile coronary-care units 3,500 2,250 1,600 800 300 207 90 74 6 6 0.2 to 2 0.2 -10 -125
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158. Cost-benefit model Cost £ Number of accidents Cost prevention - Employer Cost accidents - Employer Total Costs - Employer ‘ Optimum’ performance - Employer
189. Change Analysis: fall in Victoria Square No recognition of changed circumstances /route Walking/observing on ‘autopilot’ Walking/observing on ‘autopilot’ Attention directed to stall produce Market stalls a significant distraction No unusual ‘distractions’ Also, carrying a shoulder bag and rucksack Pedestrians difficult to navigate around Pedestrians few and no effort to navigate around Diversion necessary from normal route (one step to descend) Frankfurt ‘Christmas’ Market in operation No physical barriers for normal route (and no steps) Anxiety about Course Stress state ‘elevated’ Stress state ‘normal’ Result of dealing with arrangements for AI Course at last minute More preoccupied than usual when going to catch (the) train Preoccupied when going to catch a train Indicates that IP (me) was not walking unduly fast, as was the case Time to get to station 35m Time to get to station 30m Comments Accident situation Normal Situation
190. Change Analysis: fall in Victoria Square - consequences Emergency admission to hospital suffering from whiplash injuries three days later Fall on unseen step, and arrival at station bloody and shaken Delegates at AI course impressed by this Change Analysis! Safe arrival at station Situational violation (need to catch the train) Cancelled ambulance despite police advice (and not given necessary treatment) Accept full first aid treatment Comments Accident situation Normal Situation
198. Fatality due to FLT collision & FLT Collides with person & Victim Dies Person in the FLT Path FLT Fails to Stop Not aware of Need to Stop Aware but unable to Stop Driver actually Ill Driving Too fast Faulty Brakes Not Aware of Person Thinks person will evade 1 Person Aware of FLT Unaware of FLT Thinks FLT will Evade Unable to move out of way Person actually Ill Person Slips/trip Falls Disabled Time too short & Person Did Not See FLT Person Did Not Hear FLT 2 3 Poor visibility Vision obstructed Not looking Reversing Person Conspicuity Poor visibility Vision obstructed Not looking visually impaired FLT Conspicuity Wearing PPE Noisy place FLT quiet Wearing stereo Hearing impaired FLT Accident Investigation
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200. Events and Casual Factors General Format Systemic Factors Contributing Factors Systemic factors Contributing factors Secondary events Primary events
ACCIDENT Investigate accident - process and outcome steered by the preconceptions of the investigator about accident causation Attribute primary cause to shortco mings in the behaviour of the injured person (unsafe acts) Devise a RULE forbidding the recurrence of the unsafe acts Attribute primary cause to shortcomings in the physical environment (unsafe conditions) Devise a TECHNICAL solution to make the conditions safe
Notes
The International Nuclear Safety Advisory Group (IAEA 1991) has defined safety culture: “ Safety culture is that assembly of characteristics and attitudes in organisations and individuals which establishes that, as an overriding priority, nuclear plant safety issues receive the attention warranted by their significance.” They suggest that “the definition relates Safety Culture to personal attitudes and habits of thought and to the style of organizations.” They go on to say: “ A second proposition then follows, namely that such matters are generally intangible ; that nevertheless such qualities lead to tangible manifestations ; and that a principal requirement is the development of means to use the tangible manifestation to test what is underlying .” my italics] INTERNATIONAL NUCLEAR SAFETY ADVISORY GROUP. Safety culture. Safety Series , 1991, 75-INSAG-4 (IAEA, Vienna)
Notes More detailed information about the key requirements of the Regulations is given in the Resource Materials starting at page RM4.
Notes More detailed information about the key requirements of these Regulations is given in the Resource Materials starting at page RM7.
Notes More detailed information about the key requirements of these Regulations is given in the Resource Materials starting at page RM7.
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