Accident Precursor Analysis and Management Reducing Technological Risk Through Diligence (2004) / Chapter Skim
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Section I Committee Summary Report1 The Accident Precursors Project: Overview and Recommendations
Section I Committee Summary Report1 The Accident Precursors Project: Overview and Recommendations
Pages 1-34
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Section I Committee Summary Report
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The workshop presentations addressed four general areas: . The Opportumty of Precursor Analysis (Section 11)
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The Committee on Accident Precursors evaluated the presentations and discussions, as well as additional submissions from Drs. Frosch and West um (Appendixes A and B)
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John Ca roll of the Sloan School of Management of the Massachusetts institute of Technology discussed how knowledge about potential accidents could be shared throughout an organization, both formally and informally. The last group of speakers described approaches to engaging stakeholders, institutions, and industries in the process of identifying and managing accident precursors.
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The first topic addressed m this summary is the opportunity presented by accident precursors for improving safety. Next, a case is made, based on historical examples, for the need for a better mlde s[auldillg of precursor management.
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Moreover, it may be impossible to develop a precise definition of reportable precursors in relatively new or immature technologies md systems or in systems for which no qu mtitative risk analyses are available. Conversely, setting the threshold for reporting too low runs the risk that the reporting system may be overwhelmed by false ala ms, especially if the system desigm requires some corrective action or substantial analysis for all reported events.
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, and precursor reporting systems are typically used for technologies in which unforeseen problems can have serious consequences. THE OPPORTUNITY OF PRECURSOR MANAGEMENT Programs for managing accident precursors have a number of benefits, as outlined by van der Schaaf et al.
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To benefit from near misses, organizations ranging from hospitals to manufacturing facilities and airlines to power plants, have set up management systems for reporting and analyzing near misses (see examples documented in this report and Barach and Small, 2000; Bier and Mosleh, 1990; Jones et al., 1999; van der Schaaf, 1992)
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Comparing Accident Analysis and Precursor Analysis One of the most attractive aspects of precursor analysis is the abumdamce of precursor events compared to actual accidents (Bred and Gemmain, 1996)
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For example, corrective actions developed m response to precursor data may be less persuasive md more open to question than corrective actions based on actual accidents (March et al., 1991)
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describe m example of a plant, the Millstone Nuclear Power Station, m New London, Connecticut, that underwent m org~mizational shift and became a safety-conscious work environment that exhibited many of the characteristics associated with a healthy safety culture. In 1996, the Millstone Nuclear Power Station was featured m a Time magazme cover story as a rogue utility that cut corners and intimidated or feed employees who raised safety concerns (Pooley, 1996)
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For example, incidents that involve clear violations, such as criminal or malicious behavior, are typically managed separately from precursor programs to avoid protecting mdividuals who have committed such violations. Other incentives to encourage precursor management could include monetary or other rewards for compames that institute programs to identify and collect data on precursor events.
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. The CAIB report concluded that, although certain precursor events m missions prior to STS-107 had indicated problems, their continued occurrence without resulting in accidents had led to a misperception they were consistent with normal operation.
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INTRAORGANLZATIONAL SHARING AND ANALYSIS OF PRECURSOR INFORMATION Some researchers believe that certain complex, tightly coupled, high-hazard organizations routinely mamtam better than expected levels of safety and reliability. These are generally referred to as "high-reliability organizations" (HROs)
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Sharing of information across organizations is important because m my hallmark accidents that have drawn attention to the import rice of precursor m magement were preceded by similar but non-catastrophic precursor events m other organizations. Because of a lack of effective mformation exchange, the org~mization that experienced the eventual accident was often unaware that others had learned from md acted on related precursor events.
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can expand the range of information available to an organization and can counteract complacency and the normalization of deviance. SAMPLE INDUSTRY APPROACHES A number of industries have implemented programs for taking advantage of precursor information, several within the past few years.
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Accident Sequence Precursor Program The ASP Program, overseen by the U.S. NRC, analyzes and disseminates findings from potential precursor events at U.S.
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5, Following up on ERC recommendations for corrective actions to assess whether they have been satisfactorily accomplished. Several demonstration programs initiated after a 1997 advisory circular (DOT-FAA, 1997)
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. An alternative approach is to implement surveilLmce systems that automatically monitor for precursor events and to establish work processes to ensure that when m incident is detected, the impending accident is averted.
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The collection, filtering, and analysis of accident precursor data, followed by the implementation of corrective actions, can improve reliability md safety.
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Precursor Management The effective management of precursors, near misses, and close calls poses a number of challenges. Managing a single incident involves recognizing that a precursor has occurred, ensummg that the event is reported, and imalyzmg the event to assess its causes and identify possible corrective actions.
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(2003) cite examples from the chemical indust y of personnel idennfying precursor events that would have been of interest to management but not reporting them because they did not match the stated definition of the precursor program.
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Prioritizing Precursors and Disseminating Precursor Information Finding 5. Organizations considering or implementing precursor programs face a variety of challenges, including filtering and prioritizing reports for effective analysis and identifying sound nsk-reduction responses to observed precursors.
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A number of approaches are cur ently used to prioritize precursors. In some programs, one or more individuals involved in the program simply screen precursor events md pnontize them subjectively.
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occur to the private sector. Therefore, to reduce accident rates through precursor management, the private sector must be actively engaged in identifying and managing precursor events.
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Organizations should support md participate in crossmdustry collaborations on precursor management md research. Engaging Government Even though government institutions are abready engaged m facilitating the reporting and malysis of precursors, the committee believes that govemtnent could do more to foster the cross-company and cross-industry sharing of information.
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Finally, incentives for sharing information about risks may differ from one industry to another Steps that c m be taken to encourage the adoption of precursor programs include providing economic incentives for information sharing, aligmng market mechanisms to encourage precursor management (e.g., through reductions m msunmce premiums) , and third-party inspections of carp orate nskm~magement programs (Ca roll and Hatakenaka, 2001; Kunreuther et al., 2002)
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In addition, funding agencies and foundations should support basic research on using accident precursors m risk management programs md the characteristics of effective precursor information martAgement.
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Despite the best engineering practices, and despite strict adherence to standards and ongoung mamtemmce, indicators of future problems Can and do arise Org mizations that formally search for and manage accident precursors c m continually find opportumties for improvmg safety and c m thereby reduce the probability of disasters. HEFEHENCES Armstrong, J.S.
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Risk Analysis 12(3)
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Risk Analysis 22(2)
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2003. Near miss incidem manage mem in the chemical process industry.
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2002. A Symhesis of Safety Culllte and Safety Climate Research.
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