WOS2006| 2 3 Fear of harm ought to be proportional not merely to the gravity of the harm, but also...

W O R MW O R M

2WOS2006| W O R MW O R M

W O R MW O R M


Fear of harm ought to be proportional not merely to the gravity of the harm, but also to the probability of the event

A. Arnoud, La Logique, or l’art de penser, 1662


Primary objectives• Development of a methodology to support the definition of a risk

reduction strategy– Optimising reduction of consequences, probabilities and costs

• Application of the methodology to 25 hazardous activities– That take place in activities or occupations– Allowing the construction of a risk profile for that occupation– And developing a risk reduction strategy

• The ultimate application takes place in the enterprises.


Project managerMinSZW(J. Oh)

Project managerMinSZW(J. Oh)

Product manager (B. Ale)

Product manager (B. Ale)

Software(L. Bellamy)

Software(L. Bellamy)

Managementfactor

(A. Hale)

Managementfactor

(A. Hale)

Storybuilding(L.Bellamy/A. Hale)

Storybuilding(L.Bellamy/A. Hale)

Bowtiebuilding(I. Papazoglou)

Bowtiebuilding(I. Papazoglou)

Technical secretary(J. Versteegen)

Technical secretary(J. Versteegen)

Project coordinatorMinSZW(J. Drost)

Project coordinatorMinSZW(J. Drost)

Organisation

Product manager (A. Bloemhoff)

Product manager (A. Bloemhoff)

Survey(J. Klein

Hesselink)

Survey(J. Klein

Hesselink)

Costs of measures

(M. Damen)

Costs of measures

(M. Damen)

Quantification(R. Whitehouse)

Quantification(R. Whitehouse)

Datawarehouse(A. Eykelestam)

Datawarehouse(A. Eykelestam)

J. WhistonO. AnezirisM. MudH. BaksteenJ.P. van ‘t Zand

L. GoossensM. MudM. DamenM. SamwelC. PaasJ. QuikP. SprengerP. van Grieken

R. WhitehouseS. VerschoofJ. PaapJ. Klein Hesselink

I. PapazoglouA. Bloemhoff

10 August 2005Advisory committeeT. Maddison (HSE)K. Jorgensen (Danish LI)M. Christou (EU-JRC)

Advisory committeeT. Maddison (HSE)K. Jorgensen (Danish LI)M. Christou (EU-JRC)

A. Bloemhoff


Ca

use

s

Co

nse

que

nce

s


Fault-tree

Accident

Ba

sic

cau

sse

s

Event-tree

Damage

Bow-tie

Everything leading up to the accident

Verything following the accident


Prevent accidents

Take away causes Make barriers


Fault-tree

Ba

sic

failu

re e

ven

ts

Event-tree

Outcomes

rotha

Effectiveness of a barriers Need number before and

after


Barriers are not perfect


Leve

l of m

easu

res

populationWithreportableaccidents

populationwithoutreportableaccidents


METRIC

• The injury classes are– Death– Permanent injury– Recoverable injury

• Risk is expressed as the frequency of having each of the three possible consequences per year of work.


“I gashed my eye open there a couple of times with hooks flying.......Cut my eye open right down across there. I lost a lot of blood, it went pretty deep when the hook hit my eye” (it hooked between the bridge of his nose and his eye and tore upwards about 1 and a half inches.) ” (Example Horrible Story)

Horrible stories (reminder)


Volume

• 10000 accidents: to analyse• Enter the storybuilder (another paper in this

conference)


1 CEFal l from

ladder/ s teps o r

2 GPSB Fa i lu re

(Grouped)

3 GM FM anagem ent Tas k s

4 GM FGenera l

M anagem ent

5 A

Ac tiv i ty

7 EQEqu ipm entTy pe

9 IF

Bik c ode

11 IF

Pro fes s ion

13 IFWork ing

re la tion

8 IFM ob i le

ladder

10 IFs tep ladder

o r s teps

12 IFFix ed

ladder

14 IFRope ladde

r

15 IF

s ta i rs

6 AM ov ing up/

down a s tep /

16 AM ov ing

up/down

17 Ains pec ting/

ad jus ting /m eas u

18 A(de-)ins ta l l i

ng/ repa i ring on

19 Ac leaning /

pa in ting on

20 Ac ons truc tio

n re la ted

21 Aother

ac tiv i ty on

22 M FPlans and

proc edures

23 M F

Av a i lab i l i ty

24 M FEqu ipm ent

(too ls , s pares ,

25 M FConfl ic t

res o lu tion

27 M FM otiv a tion/

c om m itm ent

26 M FCom petenc

e

28 M FCom m un ica tion

29 M FErgonom ic

s / M M I

30 M F

Unk nown

31 CLE

Prov ide

32 M TProv ide

righ t equ ipm ent

33 M TProv ide

proc edures &

34 M TProv ide

add i tiona l s a fe ty

36 M TProv ide

s afe work ing

37 M TProv ide

s afe s urfac es

38 M TProv ide

s afe ac c es s to

35 M TRis k

Iden ti fic a tion &

39 CLEOperate

(us e)

40 M TM is m atc h

too l -ac ti v i ty

41 M TEns ure

proc edures fo r

42 M TEns ure

s afe p roc edures

43 CLE

M ain ta in

44 M TIns pec t &

m a in ta in ladders

45 CLE

M on i to ring

46 SSBFWrong /

s ubs tandard

54 SB1Righ t ladde

r 47 BFSubs tandar

d c ond i tion o r

50 BCond i tion

o f ladder

51 BSMRigh t

c ond i tion o f

52 IFCond i tion

o f an ti -s l i p

53 IFDim ens ion/

ty pe o f ladder/

48 LCELadder fa i l

s

49 PSFLadder

Streng th

55 SSBFPlac em ent

& p ro tec tion

62 SB2Plac em ent

& Pro tec tion

56 BFWrong

p lac em ent o f

58 BCorrec t

p lac em ent o f

59 BSMCorrec t

p lac em ent o f

60 IFWet and /o r

s l ippery s u rfac e

61 IFSupport

/s u rfac e-c ond i tio

57 LCELadder/

s teps m ov es

63 BFWrong

loc a tion o f ladde

66 BSafe

loc a tion o f ladde

67 BSMSafe

loc a tion for the

68 IFHi t by

v eh ic le

69 BWTSEE

BOWTIE 2

70 IFHi t by

fa l l ing / m ov ing

71 BWTSEE

BOWTIE 3

64 LCELadder/

pers on i s h i t

65 PSFLadder

Stab i l i ty

72 BFSubs tandar

d s u rfac e /

74 BCond i tion

o f s upport/

75 BSMRigh t

s urfac e/ s upport

76 BWTSEE

BOWTIE 1 .3

73 LCESupport/

s urfac e fa i l s

77 SSBFAbi l i ty to

us e ladder fa i lu r

82 SB3Abi l i ty to

us e the ladder

83 BFSubs tandar

d pos i tion o f

85 BCorrec t

pos i tion on

86 BSMCorrec t

pos i tion o f

84 LCEOv erreac h i

ng leads to los s

78 BFSubs tandar

d c ond i tion /

80 BFi tnes s /

c ond i tion o f

81 BSM(Phy s ic a l ly

) fi t pe rs on on

79 LCEPers on

gets unwe l l

87 BFLos s o f

c on tro l ov er

90 BCorrec t

c are / a ttention/

91 BSMCorrec t

c are / a ttention /

92 GInc ident

fac to rs

88 LCEUnc on tro l le

d m ov em ent/

89 PSFUs er

Stab i l i ty

106 LCEIm pac t by fa l l

107 GInc ident

fac to rs

108 IFHeight o ffa l l

109 IF0m <

Height o f fa l l <=

110 IF1m <


111 IF2m <


112 IF3m <


113 IF5m <


114 IFHeight o f

fa l l > 10m

115 IFHeight o f

fa l l unk nown

116 IFUnk nown

s urfac e ty pe

117 IFHard

s urfac e

118 IFSoft

s urfac e (s o i l ,

119 IFPers on

undernea th

120 IFObjec ts in

l ine o f fa l l

182 BFNo us e o f

fa l l a rres tors or

183 BUs e of fa l l

p ro tec tion

184 BSMUs e of fa l l

a rres tors / s a fe ty

185 BFInadequa t

e fa l l a rres tor

121 GDos e-Res

pons e Fac tors

177 BFNo

(adequa te )178 BEm ergenc

y Res pons e

179 BSMAdequate

em ergenc y

180 IF

Age

181 IF

Gender

122 GNum ber o f

c as ua l ties

123 INJ N

N o f C = 0

124 ENDEnd, no

c as ua l ti es

171 INJ N

N o f C = 1

172 BWTSEE

BOWTIE 3

173 BWTSEE

BOWTIE 3

174 INJ N

N o f C = 2

175 INJ N

N o f C = 3

176 INJ NN o f C >=4

125 GPart o f

body in ju red

127 GTy pe o f

in ju ry

129 GHos p i ta l is

a tion

130 HOSPH =

Hos p i ta l is ed

132 HOSPNH = Not

Hos p i ta l is ed

302 HOSPNHS =

Unk nown

131 FOD

Death

133 FOP(Probably )

pe rm anently

134 GAbs enc e

from work

135 IF

<= 1 day

136 IF1 day <

abs enc e <= 1

137 IF

> 1 week

138 IF1 week <

abs enc e <=1

139 IF

> 1 m onth

140 IF<= 6

m onths

141 IF> 6 m onth

s

142 IF

unk nown

143 FOI(Probably ) Non

144 FO

Unk nown


Company

Job Job

JobJob

Activity 1Activity 2…..

Hazard

Hazard

Hazard

CECE

CECE

CECE


Jobprofile

CECE

CECE

CECE

Activity nr Time or nr of missions

123456

No risk…….

RISK

For ‘jobtitle’


BowtieBowtieBuilderBuilder

Accident dataAccident data StoryStoryBuilderBuilder

ScenariosScenarios

NormsNormsStandardsStandards

RegulationsRegulations

Bowties andBowties andBarrieresBarrieres

CostCost

OptimizerOptimizer

OptimalOptimalRisk Risk

reductionreduction

ProbabilitiesProbabilitiesManagementManagementFactorsFactors

ExposureExposure


Ladders

Probability Influencing EntityInfluences one block at the

time


PIEPIE

Measure 1

PIE

Measure 2

PIE

PIEPIEMeasure 3

Strategy 1

Strategy 2

Strategy 3

Bow-TieBlock

Bow-TieBlock

Cost 1

Cost 1

Cost 1

Optimiser



Human influence

DELIVERIES

ProceduresEquipmentErgonomicsAvailabilityCompetenceCommunicationMotivationConflict-resolution

TASKSProvideUseMaintainMonitor

Barrier


PSB’s

plac&prot

ability

right ladder

stre

ng

th

sta

bili

ty

sta

y o

n

SSB’s

Cause Fall

DELIVERIES



DELIVERIES





SSB

SSB

PSB CE

P+cond (SSB = +)

BFE

BFE

LCE

BFE

BFE

LCE

% of paths = max reduction

Also for PUMM

Measure

Change % + state

DELIVERIES



DELIVERIES





DELIVERIES




DELIVERIES



DELIVERIES



DELIVERIES







DELIVERIES



DELIVERIES






Data selection

Offence Inspectiepunt (overtreding)

Investigation report onderzoeksrapport

Reportable according to telefonische melding meldingsplichtig

Number of cases

Total

Y Y U 2 N Y U 27 N Y Y 4558 Y Y Y 6508 Y N Y 153 Y N N 232 Y Y N 482 N Y N 693

In Storybuilder set 12,655

N N U 23 N N Y 1810 N N N 8404

Not in Storybuilder set 10,237

TOTAL 22892


Further selection

Reported accidents, according to telefonische melding 22,892 No offence and no investigation report 10,237 Reported accidents where after the telefonische melding coded information is put in GISAI with offence and/or investigation report

12,655

Accidents that are coded in bowtie 3 and 8.1 from 1998-2001 And accidents that are coded in bowtie 18, 19, 21 and 26 (± one accident/year) And reports that contain insufficient information

2,862

Analysed accidents 9,193 Not an arbeidsongeval after investigation 89 Unknown bowtie 22 Total number of cases analysed in Storybuilder 9,082


1.1.1 Fall from ladder & steps Fall from placement ladder 1.1.1.1Fall from fixed ladder 1.1.1.2Fall from steps 1.1.1.3Fall from rope ladder 1.1.1.4

1.1.2 Fall from scaffold Fall from scaffold 1.1.21.1.3 Fall from height roof/platform/floor Fall from height roof/platform/floor 1.1.31.1.4 Fall from height hole in the ground Fall from height hole in the ground 1.1.4

1.1.5.1 Fall from moveable platform Fall from moveable platform 1.1.5.11.1.5.2 Fall from non-moving vehicle Fall from non-moving vehicle 1.1.5.21.1.5.3 Working on height unprotected Working on height unprotected 1.1.5.3

2 Struck by moving vehicle Struck by moving vehicle 23.1 Contact with falling object - cranes Contact with falling object - cranes 3.13.2 Contact with falling object - other Contact with falling object - other 3.24 Contact with flying object Contact with flying object 45 Hit by rolling/sliding object or person Hit by rolling/sliding object or person 56 Contact with object person is carrying or using Contact with object person is carrying or using 67 Contact with hand held tools operated by self Contact with hand held tools operated by self 7

8.1 Contact with moving parts of a machine Contact with moving parts of a machine - operating a machine 8.1.1Contact with moving parts of a machine - maintaining a machine 8.1.2Contact with moving parts of a machine - clearing a machine 8.1.3Contact with moving parts of a machine - cleaning a machine 8.1.4

8.2 Contact with hanging/ swinging objects Contact with hanging/ swinging objects 8.28.3 Trapped between/against Trapped between/against 8.39 Moving into an object Moving into an object 910 Buried by bulk mass Buried by bulk mass 1011 In or on moving vehicle with loss of control In or on moving vehicle with loss of control 1112 Contact with electricity Contact with electricity 1213 Contact with extreme hot or cold surfaces or open flame Contact with extreme hot or cold surfaces or open flame 13

14.1 Release out of open containment Release out of open containment 14.114.2 Contact with hazardous substance without LoC Contact with hazardous substance without LoC 14.215 Release out of closed containment LoC - Adding/removing a containment 15.1

LoC - Transport of closed containment 15.2LoC- Closing a containment 15.3LoC - Activities nearby a closed containment 15.4

17 Fire Fire 1718 Exposure to damaging noise dose will not be modelled19 Exposure to damaging non-ionising radiation dose will not be modelled

20.1 Victim of human aggression Victim of human aggression 20.120.2 Victim of animal behaviour Victim of animal behaviour 20.221 Trapped in hazardous spaces no cases

22.1 Contact with hazardous atmosphere in confined space Contact with hazardous atmosphere in confined space 22.122.2 Contact with hazardous atmosphere through breathing apparatusContact with hazardous atmosphere through breathing apparatus 22.223 Impact by immersion Impact by immersion 2324 Too rapid (de)compression only 3 cases; no separate model (for time being included in 23)25 Extreme muscular exertion Extreme muscular exertion 2527 Explosion Physical explosion 27.1

Chemical explosion 27.2



Hazardous chemicals


Heinrichs Triangle

Deaths

1

Permanent injuries

10

Recoverable injuries

30


Deaths

1

Permanent injuries

10


30

1.1.1. Ladder accidents

• Every year there are on average 3 deaths from falls from a ladder, 30 permanent injuries and 90 recoverable serious injuries


Deaths

1

Permanent injuries

5


35

1.1.2. Scaffold accidents

• Every year there are around 70 falls from scaffold accidents


Deaths

1

Permanent injuries

7


9

2. Struck by moving vehicle

• Every year there are around 120 work accidents where a person is

struck by a moving vehicle.

• 6% of cases analysed resulted in death

• In all the cases of death the victim was in an area normally

designated “safe”

• In all cases management failed to provide adequate barriers at some

point in the scenarios


Deaths

1

Permanent injuries

5


4

3. Falling/dropped/collapsing objects

• Every year there are on average 240 accidents


8.1 Machine accidents

• A first pass assessment suggests that every year there are around 500 machine accidents in Nederland involving contact with moving parts

Deaths

1

Permanent injuries

40


10

Humans are no match for machines


Occupational accidents (Netherlands)

2003 TotalAgriculture /fishery

industry /mining Building

transport /storage /cummunication Other Unknown

CBS 83 12 21 22 8 17 3RIVM 104 13 23 23 12 24 9number of employees 7869000 219000 1046000 465000 467000 5415000 257000accident rate (CBS) 10.5 54.8 20.1 47.3 17.1 3.1 11.7Accident rate (RIVM) 13.2 59.4 22.0 49.5 25.7 4.4 35.0


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