Causes of accident review paper in industries. Focus on Oil and gas sector from HSE view point.

1. Causes of Accidents in Industries: A Comprehensive Analysis
1. Introduction
In the dynamic landscape of industrial operations, the pursuit of enhanced safety remains a
paramount concern. Accidents in industries not only pose immediate threats to human lives
but also cause significant economic and environmental repercussions. Understanding the
causes of accidents is crucial for implementing effective preventative measures and fostering
a safer working environment. This research endeavours to provide a comprehensive analysis
of the causes of accidents in industries, with a specific focus on three primary factors:
Human factor, Work Environment, and Management.
The interplay of human actions, the surrounding work environment, and managerial
decisions constitutes a complex web that contributes to the occurrence of industrial
accidents. Human factors, encompassing elements such as individual behaviour, cognitive
aspects, and training protocols, play a pivotal role in determining the likelihood of accidents.
Concurrently, the work environment, inclusive of physical conditions, safety protocols, and
ergonomic considerations, directly influences the frequency and severity of accidents.
Additionally, the decisions and practices adopted by management significantly impact the
overall safety culture within an organization.
This study aims to delve into the intricacies of these three crucial dimensions—Human
factors, Work Environment, and Management factors—shedding light on their individual
contributions and examining their interconnectedness. By undertaking a thorough analysis,
we seek to identify patterns, trends, and critical intersections that can inform targeted
interventions for accident prevention. Through an evidence-based approach, this study
endeavours to provide insights that can empower industries to proactively mitigate the risks
associated with accidents and cultivate a safer and more resilient operational environment.
As we navigate the complex terrain of industrial safety, this study represents a step towards
enhancing our understanding of the root causes of accidents. By synthesizing knowledge
across these key domains, we aim to contribute to the ongoing discourse on industrial
safety, ultimately fostering a culture where accidents become increasingly preventable and
workplace well-being takes precedence.
Significance of studying the causes of accidents
Studying the causes of accidents in industries is of paramount importance for several
reasons, and it plays a crucial role in promoting safety, preventing future incidents, and
improving overall workplace conditions. Here are some key reasons why studying the causes
of accidents is significant:

2. Employee Safety: The primary concern is the well-being of employees. Understanding the
causes of accidents helps identify hazards and risks, allowing organizations to implement
effective safety measures to protect workers from harm.
Prevention: By analysing the root causes of accidents, organizations can develop strategies
and implement preventive measures to avoid similar incidents in the future. This proactive
approach helps create a safer work environment.
Compliance: Many industries are subject to various safety regulations and standards.
Studying the causes of accidents helps organizations ensure compliance with these
regulations, avoiding legal repercussions and penalties.
Cost Reduction: Accidents can lead to significant financial losses due to medical expenses,
compensation claims, damaged equipment, and downtime. Identifying the causes and
implementing preventive measures can reduce these costs and improve overall operational
efficiency.
Productivity: Safe workplaces contribute to higher employee morale and productivity. When
employees feel secure, they are more likely to focus on their tasks and contribute to the
success of the organization.
Reputation Management: Accidents can tarnish a company's reputation, affecting its
relationships with customers, suppliers, and the community. By demonstrating a
commitment to safety and addressing the causes of accidents, organizations can protect and
enhance their reputation.
Learning and Improvement: Studying accidents provides valuable insights into
organizational weaknesses and areas that need improvement. This continuous learning
process helps companies refine their safety protocols and emergency response procedures.
Legal and Ethical Obligations: Organizations have a legal and ethical responsibility to provide
a safe working environment for their employees. Studying the causes of accidents
demonstrates a commitment to fulfilling these obligations.
Insurance Considerations: Companies with a strong safety record may be eligible for lower
insurance premiums. Analysing accident causes and taking steps to reduce risks can
positively impact insurance costs.
Industry Benchmarking: Comparing accident data with industry benchmarks allows
organizations to assess their safety performance relative to others in the same sector. This
benchmarking can lead to the adoption of best practices and continuous improvement.
In summary, studying the causes of accidents in industries is essential for safeguarding
employees, preventing future incidents, meeting legal obligations, and improving overall

3. organizational performance and reputation. It is a proactive approach that fosters a culture
of safety and well-being in the workplace.
2. Literature Review
2.1 Human factor risk management in the process industry: A case study (2018)
By Maurizio Bevilacqua, Filippo Emanuele Ciarapica
The Safety, Quality and Environment (SQE) committee of the refinery has shown that human
error is a main contributory cause to more than 30% of adverse events, 70% of which could
have been prevented by management actions. The SQE committee identifies as human
errors what Reason called “Person Approach”, the longstanding and widespread tradition of
the person approach focuses on the unsafe acts—errors and procedural violations.
2.2 Human Factors and Safety Management: a Field Study on Safety Performance in the
Process Industry (2019)
By Bruno Fabianoa, Margherita Pettinatoa, Andrea P. Reverberib, Fabio Curròa
The study emphasizes that human errors in occupational settings are multifaceted, often
stemming from various contextual factors rather than mere incompetence or lack of
attention. Despite a decreasing trend in occupational fatalities and injuries in Italy over the
past three decades, avoidable injuries persist due to human factors. These factors include
insufficient training, motivation, physical or mental ability, and lapses in attention. Efforts to
understand the cultural causes of workplace safety are ongoing. The research underscores
the need for comprehensive approaches like training, procedures, supervision, and
leadership to break accident trajectories. Examining accidents over an extended timeframe
through proper statistical analysis contributes to improved risk assessment and
management. The study specifically investigates the role of human factors in a downstream
oil industry using a structured questionnaire, aiming to enhance safety management by
considering the human element and advocating for a dynamic decision-making principle that
goes beyond static balance.
2.3 A field study on human factor and safety performances in a downstream oil industry
(2022)
By Bruno Fabiano, Margherita Pettinato, Fabio Curro, Andrea P. Reverberi
This paper has presented an experimental study focused on the perceptions of workers of a
downstream oil industry relating to different aspects of the safety culture and management
in their workplace, including use of procedures and perceived occupational accident causes.
A large-scale study involving 507 workers of two process plants and 176 external workers
was conducted to investigate relevant safety issues. Despite some limitations, the study
provides comprehensive information regarding human factor influence in actual and
potential accidents, possibly addressing improvement in the firm safety policy, as well as
program development for promoting safety culture. The evaluation approach, even if

4. currently developed at a prototype level, allows the enforcement of several practical
intervention lines based on questionnaire results. Based on this study, several
recommendations are made for safety improvement in the plant studied. Indeed, through
the recognition of the most influencing factors, improvement items in the HSE management
system can be identified and the most effective layers of protection, both mitigating and
preventing the risk can be implemented. In view of future investigation, the evolution over
time of worker safety behaviour, attitude, and awareness, as well as the efficiency of training
programmes can be quantitatively assessed by the presented framework, adopting
presented empirical results as an internal benchmark of reference.
Individual Behaviour
Individual behaviour of the workers is determined by considering four relevant categories:
behaviour, attitude towards safety, reaction near-miss / incident, communication.
Formally, a clear behavioural attitude of respect towards the operating procedures and
attention for hazards relating to specific activities, together with a proactive operational
approach emerged from collected data. Similar attitude was reported by the outsourced
workers’ questionnaires. As elements of deviation, it should be noted that 45.3% of answers
indicated that occasionally violations took place, related to those risks which are considered
less serious, or less likely (e.g., failure to use personal protection equipment (53.6%), failure
to observe regulations on vehicular traffic (60.1 %)). The high number of nonresponses
related to particular questions could indicate that workers were aware about the danger of
certain actions and the tendency to maintain these behaviours. Particularly, daily workers
showed less attention related to the use of personal protection equipment (68.1 %)
compared to shift workers (40.9 %). Recommendations: a) targeted training on specific risks
and behavioural role; b) random field supervision and Inspection by the management; c)
speed control systems of vehicles in transit and traffic offences, combined with proper
economic fines in case of rule violations.
Human resource management (HRM)
The aspect related to HRM in the questionnaire was explained under four categories:
procedure, education and training, accountability, motivation
Concerning the dimension Procedure, 72% of the workers showed positive intent by
following procedures related to safety. However, an issue connected to procedure updating
emerged from responses. 87.4% of the validated responses showed a formal adherence to
procedures when operations are carried out by outsourced workers. It is worth noting that
according to a cross analysis between the results of the questionnaire and adverse events or
accidents, 73.9% of the responses revealed the presence of a number of procedures, which
were not followed fully, or were mainly disregarded. As explained by further analysis, it
appears that the worker adhesion to procedures is determined by the experience level of

5. the worker rather than by the complexity of the specific task. The reason seemed to be
traced back to the lack of definition of responsibilities in the procedures and the limited
clarity of the protocols. Especially daily workers were involved in this failure. 63.2% of the
responses indicated the impossibility of finding an interlocutor for solving problems that
arise, while 73.0% claimed explicit difficulties in applying certain procedures. For outsourced
workers, the procedures relating to occupational safety were disregarded to a higher degree,
indicating a moderate control issue. Recommendations: in order to reduce hazards,
procedure verification is recommended, as well as simplification to the greater extent
possible.
“Education and training” is the most critical factor in the Human Resources management
dimension of HSE. Workers generally consider education and training as important and
safety relevant elements. Indeed, only a small percentage (8.9%) of the responses of internal
workers showed less sensitivity/ interest in training. This result was fully statistically
consistent with the sensitivity to safety issues mentioned in other dimensions. 96.8% of
outsourced operators followed a course of training in the last 2 years and for the 78.8 % of
respondents the received formation was recognised as satisfactory. The most striking
statistical figure is the number of non-responses (36.9%) and staff who do not remember
(7.7%) for a total of validated responses to negative value equal to 44.6%. These results also
showed that for internal workers the investment and commitment to the training was
satisfactory, but perception and effectiveness of the training program was not adequate.
Operators indicated an extremely variable number of hours of training attended in the last
two years ranging from 1 to over 100.
2.4 Human and organizational factors influencing structural safety: A review (2024)
Xin Ren a, Karel C. Terwel b, Pieter H.A.J.M. van Gelder
Human errors and failures are inherent in the engineering process, yielding valuable lessons
that drive engineering advancement. Active and continuous learning of underlying
conditions behind errors and failures can mitigate recurrent issues. Therefore, the outcomes
generated from such a comprehensive review are beneficial for academics and practitioners
in the AEC industry for a better understanding of HOFs to improve structural safety.
Furthermore, this review aims to motivate future research on HOFs influencing structural
safety in a multidisciplinary and systematic fashion.
2.5 Human error: models and management (2003)
By James Reason
The human error problem can be viewed in two ways: the person approach and the system
approach. Each has its model of error causation and each model gives rise to quite different
philosophies of error management. Understanding these differences has important practical
implications for coping with the ever present risk of mishaps in clinical practice.

6. High reliability organisations are the prime examples of the system approach. They
anticipate the worst and equip themselves to deal with it at all levels of the organisation. It is
hard, even unnatural, for individuals to remain chronically uneasy, so their organisational
culture takes on a profound significance. Individuals may forget to be afraid, but the culture
of a high reliability organisation provides them with both the reminders and the tools to help
them remember. For these organisations, the pursuit of safety is not so much about
preventing isolated failures, either human or technical, as about making the system as
robust as is practicable in the face of its human and operational hazards. High reliability
organisations are not immune to adverse events, but they have learnt the knack of
converting these occasional setbacks into enhanced resilience of the system.
2.6 What Is the Place of Human and Organisational Factors in Safety?
By Claude Gilbert
The study discusses the evolving role of Human and Organisational Factors (HOF) in
industrial safety. Traditionally, safety analyses focused primarily on technical aspects, but
there's a growing acknowledgment that HOF play a crucial role in incidents. Despite the
recognition of their importance, there are challenges in clearly defining the scope of HOF
and determining their relative significance compared to technical factors. Decision-makers
tend to prioritize HOF only in exceptional circumstances, and those responsible for HOF
often hold low-profile positions within companies. The diversity of HOF as a subject and its
intermittent priority within companies pose obstacles. The passage explores two strategies
for integrating HOF into safety – making them a priority or incorporating them into daily
activities. There's a debate on the best approach, with one being more ambitious but
demanding consistency, and the other being pragmatic but risking dispersal of HOF
knowledge. The discussion highlights the ongoing challenge of establishing the rightful place
of HOF in industrial safety and reflects on the relationship between ordinary and exceptional
circumstances in high-risk activities.
2.7 Safety Leadership and Human and Organisational Factors (HOF)—Where Do We Go
from Here?
Kathryn J. Mearns
The study emphasizes the persistent identification of human, organizational, regulatory, and
cultural shortcomings as underlying causes of major accidents in safety-critical industries.
Despite ample data, there is a notable failure to apply lessons learned from such accidents.
Challenges faced by complex organizations are acknowledged, but stronger regulatory
oversight and accountable senior management are suggested solutions. Safety
culture/climate assessments reveal common issues, including perceived lack of senior
management commitment, communication problems, inadequate procedures, fear of
speaking up, and insufficient organizational learning. Senior managers often exhibit disbelief
and reluctance to act on feedback from these assessments, raising questions about the
reasons behind their inaction. The article suggests that a focus on profits and shareholder

7. satisfaction may overshadow safety considerations, and there is a need for competent
regulators to challenge senior managers. The workforce's involvement, assessed through
safety culture/climate assessments, is deemed crucial for achieving safer working
environments. The article encourages collaboration between regulators, senior managers,
and the workforce, emphasizing the importance of independent challenges and insights
from safety assessments in decision-making processes.
2.8 Considering Human and Organizational Factors in Risk Industries
Christian Neveu, Valérie Lagrange, Philippe Noël and Nicolas Herchin
Based on an assessment of various risk industries and insights from international experts, it
is evident that adopting a Human and Organisational Factors (HOF) approach goes beyond
mere reliance on methods and tools. Central to the effectiveness of such an approach is the
need for a profound commitment from top-level managers within the organization. This
commitment should manifest in a clear organizational ambition, including a strategic vision
and the necessary resources. Additionally, it requires a strong and visible commitment
demonstrated through daily decisions and behaviours, highlighting the integral role of
leadership in fostering a robust HOF approach.
2.9 The differential impact of organizational restructuring and downsizing on the
psychosocial work environment and safety climate in the petroleum industry (2023)
By G.E. Mathisen, T. Tjora, L.I.V. Bergh, A. Jain, S. Leka
The findings from study clarify the need to monitor and follow up psychosocial risk as well as
safety climate during restructuring and downsizing. Even though psychosocial and
organizational risks associated with restructuring have been the subject of research for the
last twenty years, they have not always been considered crucial in the industry's safety work.
Experience from the Norwegian Petroleum Safety Authority (PSA) audits has shown that
there are still significant weaknesses in the companies' follow-up of psychosocial risks. Thus,
there is need for leadership development programs in this high-risk sector that clearly
address the operational risks related to psychosocial risks and safety climate, the risk of
erosion of these safety-related factors during change, how to monitor these issues as well as
how to maintain a healthy psychosocial work environment and a strong safety climate during
organizational change.
 This study examines trends in employee perceptions of psychosocial risk and safety
climate in the Norwegian petroleum industry between 2007-2019.
 Participants who had experienced organizational downsizing, restructuring or both,
reported a significantly lower safety climate on most waves.
 Restructuring was associated with the largest decline in the quality of the
psychosocial work environment across waves.
 Combined exposure to restructuring/downsizing was associated more with a worse
safety climate.

8.  Different types of organizational change have a differential impact on the perception
of different types of risk.
2.10 Relationship Between Occupational Safety and Health Policy Principles,
Organizational Action on Work-related Stress and the Psychosocial Work Environment in
Italy (2023)
By Stavroula Leka, Luis Torres, Aditya Jain, Cristina Di Tecco, Simone Russo, Sergio Iavicoli
The research on Italy's work-related stress legislation highlights a crucial gap between policy
implementation and organizational practices. Despite the existence of specific legislation
and OSH principles, organizations in Italy predominantly focus on secondary and tertiary
interventions, such as enhancing employee coping skills and rehabilitation efforts, rather
than addressing the root causes of work-related stress through primary-level interventions.
The study suggests that organizations may lack the necessary competencies to effectively
translate risk assessments into meaningful actions, and there is a notable absence of
specialist expertise, particularly in the involvement of psychologists in health and safety
services.
Furthermore, the findings underscore the need for initiatives at the policy level to prioritize
the development of knowledge and skills within organizational OSH services. The study
emphasizes the inconsistent outcomes of organizational-level interventions, pointing to the
necessity for a more targeted approach in resource allocation. Additionally, the research
highlights that Italian policies primarily focus on compliance rather than promoting the
positive benefits of managing psychosocial risks, such as increased employee engagement
and job satisfaction. The study recognizes its limitations and calls for future research to
adopt a longitudinal design and explore national surveys for a more comprehensive
understanding of the relationship between legislation, organizational actions, and the
management of work-related stress in Italy.
Literature review findings
i. Impact of Human Factors on Safety:
Human Error Contribution: Studies (2.1 and 2.2) highlight that human error is a significant
contributor to adverse events, emphasizing the "Person Approach." Despite training and
education, multifaceted human errors persist due to factors like insufficient training,
motivation, and lapses in attention (2.2).
Behavioural Aspects: Worker behaviour, attitude towards safety, reaction to near-
miss/incidents, and communication play a crucial role. Deviations, such as occasional
violations, are reported, emphasizing the need for targeted training, supervision, and control
measures (2.3).

9. Education and Training: The effectiveness of safety measures is closely tied to education and
training. While workers recognize the importance, shortcomings in training programs and
varying levels of commitment necessitate a focus on continual improvement (2.3).
Individual Behaviour: Safety culture is influenced by workers' respect for procedures,
attention to hazards, and occasional violations. The study recommends targeted training,
field supervision, and speed control to address these behavioural aspects (2.3).
ii. Impact of Organizational Factors on Safety:
Procedure Adherence: Adherence to safety procedures is critical, but challenges arise in
updating and following procedures consistently. Lack of clarity in protocols and
responsibilities contributes to non-compliance, emphasizing the need for procedure
verification and simplification (2.3).
Human Resource Management (HRM): HRM aspects such as education, training,
accountability, and motivation significantly impact safety. Issues like procedure adherence,
finding interlocutors, and difficulties in applying certain procedures require attention and
improvement (2.3).
Leadership Role: Commitment and leadership play a pivotal role in ensuring effective Human
and Organisational Factors (HOF) integration. Leadership commitment, a clear vision, and
allocation of necessary resources are essential for a robust HOF approach (2.8).
Safety Culture Assessment: Safety culture assessments reveal common organizational issues,
including communication problems, inadequate procedures, fear of speaking up, and
insufficient organizational learning. The study advocates collaboration and independent
challenges for improved safety (2.7).
iii. Impact of Working Environment on Safety:
Psychosocial Factors: Italian legislation and OSH principles focus on secondary and tertiary
interventions, emphasizing employee coping skills and rehabilitation. The lack of emphasis
on primary-level interventions addressing the root causes of work-related stress highlights a
gap in policy implementation (2.10).
Longitudinal Impact: A study on the Norwegian petroleum industry shows that downsizing
and restructuring significantly impact safety climate and psychosocial work environments.
The need for monitoring psychosocial risks during organizational change is emphasized (2.9).
iv. Interlinkages:
Human-Organizational Interaction: The studies collectively emphasize the intricate interplay
between human and organizational factors. Worker behaviour and adherence to procedures
are influenced by organizational practices, leadership, and the overall safety culture (2.3).

10. Training and Organizational Culture: The effectiveness of safety training is intertwined with
organizational culture and leadership commitment. A strong safety culture ensures the
effectiveness of safety measures implemented through education and training (2.3, 2.8).
Policy and Organizational Actions: The study on Italy's work-related stress legislation reveals
a gap between policy intent and organizational actions, highlighting the need for
competencies and expertise. Policies focusing on compliance may overlook the positive
impact of managing psychosocial risks (2.10).
In conclusion, these studies collectively emphasize that ensuring safety is a complex and
interconnected process involving the interplay of human factors, organizational practices,
and the working environment. Effective safety management requires a holistic approach that
addresses behavioural aspects, organizational procedures, leadership commitment, and the
broader context of the working environment.

11. 3. Methodology
4. Discussion
5. Conclusion/Summary of key findings

12. References
 Maurizio Bevilacqua, Filippo Emanuele Ciarapica, Human factor risk management in
the process industry: A case study (2018).
 Bruno Fabianoa, Margherita Pettinatoa, Andrea P. Reverberib, Fabio Curròa , Human
Factors and Safety Management: a Field Study on Safety Performance in the Process
Industry (2019).
 Bruno Fabiano, Margherita Pettinato, Fabio Curro, Andrea P. Reverberi, A field study
on human factor and safety performances in a downstream oil industry (2022).
 Xin Ren, Karel C. Terwel, Pieter H.A.J.M. van Gelder, Human and organizational
factors influencing structural safety: A review (2024).
 James Reason, Human error: models and management (2000).
 Claude Gilbert, What Is the Place of Human and Organisational Factors in Safety?
 Kathryn J. Mearns, Safety Leadership and Human and Organisational Factors (HOF)—
Where Do We Go from Here?
 Christian Neveu, Valérie Lagrange, Philippe Noël and Nicolas Herchin, Considering
Human and Organizational Factors in Risk Industries.
 G.E. Mathisen, T. Tjora, L.I.V. Bergh, A. Jain, S. Leka, The differential impact of
organizational restructuring and downsizing on the psychosocial work environment
and safety climate in the petroleum industry (2023).
 Stavroula Leka, Luis Torres, Aditya Jain, Cristina Di
Tecco, Simone Russo, Sergio Iavicoli, Relationship Between Occupational Safety and
Health Policy Principles, Organizational Action on Work-related Stress and the
Psychosocial Work Environment in Italy (2023)
Others
 Oh-Jun Kwon 1, Young-Sun Kim, An analysis of safeness of work environment in
Korean manufacturing: The “safety climate” perspective (2013)
 Theoni Koukoulaki, New trends in work environment – New effects on safety (2010)

13.  Gerasimos Papadopoulos a, Paraskevi Georgiadou b, Christos Papazoglou c, Katerina
Michaliou , Occupational and public health and safety in a changing work
environment: An integrated approach for risk assessment and prevention (2010)