asse bragatto 24_feb_10

Agnello, Ansaldi, Bragatto. Pittiglio Agnello, Ansaldi, Bragatto. Pittiglio The study of near misses & the knowledge management The study of near misses & the knowledge management slide slide 11

American Society of Safety Engineers – Middle East Chapter (ASSE-MEC)American Society of Safety Engineers – Middle East Chapter (ASSE-MEC)9th Professional Development Conference & Exhibition (PDC&E)9th Professional Development Conference & Exhibition (PDC&E)

February 20-24, 2010February 20-24, 2010Kingdom of BahrainKingdom of Bahrain

The study of near misses and the knowledge The study of near misses and the knowledge management in mature industriesmanagement in mature industries

Patrizia Agnello, Silvia Ansaldi, Paolo A. Bragatto, Paolo PittiglioPatrizia Agnello, Silvia Ansaldi, Paolo A. Bragatto, Paolo Pittiglio

ISPESL - Italian Institute for Occupational Safety and PreventionISPESL - Italian Institute for Occupational Safety and PreventionVia Fontana Candida 1 – Monteporzio Catone (Roma) – 00040 ItalyVia Fontana Candida 1 – Monteporzio Catone (Roma) – 00040 Italy

Contact author: Contact author: [email protected]@ispesl.it


ACCIDENTS CONTINUE TO HAPPEN !ACCIDENTS CONTINUE TO HAPPEN !

• In In mature industriesmature industries every technical issue has been already studied every technical issue has been already studied and understood, and understood, The knowledge that is stored inside the safety The knowledge that is stored inside the safety documents is huge indeed ….documents is huge indeed …. but unfortunately accidents continue to but unfortunately accidents continue to happen!!happen!!

• In mature industries the knowledge underlying all the activities, is In mature industries the knowledge underlying all the activities, is assumed perfectly defined and formalized. Accidents happen not for assumed perfectly defined and formalized. Accidents happen not for lack of knowledge, but because it has been ignored, or forgotten, or lack of knowledge, but because it has been ignored, or forgotten, or distorted, or badly applied by the operators.distorted, or badly applied by the operators.

• A near miss that happens inside an industrial facility is a challenge for A near miss that happens inside an industrial facility is a challenge for the complex knowledge system, which rules all the activities. the complex knowledge system, which rules all the activities.

• There is a huge knowledge about safety, “sleeping” in There is a huge knowledge about safety, “sleeping” in dust covereddust covered documents. The study of near-misses has the potential to “wake up” documents. The study of near-misses has the potential to “wake up” individual pieces of knowledge and make them really useful for individual pieces of knowledge and make them really useful for operators.operators.


SUMMARYSUMMARY

Scope: Scope: Mature IndustriesMature Industries, where accidents happen not for lack of , where accidents happen not for lack of knowledge, but because it has been ignored, or forgotten, or knowledge, but because it has been ignored, or forgotten, or distorted, or badly applied by the operators. distorted, or badly applied by the operators.

Section 1 the internal proprietary Knowledge Section 1 the internal proprietary Knowledge

=>=> A digital model of the internal safety management, including A digital model of the internal safety management, including equipment and proceduresequipment and procedures

=>=> From a near-miss may start a walk trough thr safety model, to retireve From a near-miss may start a walk trough thr safety model, to retireve the speeping knowledge in internal documents (procedures, reports)the speeping knowledge in internal documents (procedures, reports)

Section 2 The external shared KnowledgeSection 2 The external shared Knowledge

=>=> The external regulatory system as knowledge repository. The external regulatory system as knowledge repository.

=>=> The methodology for finding the sleeping knowledge in external The methodology for finding the sleeping knowledge in external documents, including regulations, codes, safety alert, technical documents, including regulations, codes, safety alert, technical paperspapers


NEAR MISSESNEAR MISSES

• In this paper a wider meaning for word “near miss” has been In this paper a wider meaning for word “near miss” has been assumed, in order to include every non conforming events, as they assumed, in order to include every non conforming events, as they have the potential to forerun accidents. have the potential to forerun accidents.

• In such a way even latent conditions, which might lead to an accident In such a way even latent conditions, which might lead to an accident after a long time, may be early detectedafter a long time, may be early detected

• the case studies of the research are restricted to the facilities where the case studies of the research are restricted to the facilities where major accident legislation is enforced. (All are major accident legislation is enforced. (All are maturemature industry) industry)

• The European legislation on major accident hazard, (The European legislation on major accident hazard, (SEVESOSEVESO or or COMAHCOMAH), defines a framework, which structures the safety system ), defines a framework, which structures the safety system along the lifecycle of the plant, including hazard identification and risk along the lifecycle of the plant, including hazard identification and risk analysis, safety policy and management, operational procedures, analysis, safety policy and management, operational procedures, emergency management and periodical safety audit. emergency management and periodical safety audit.

• near-misses analysis is a part of the safety management system. near-misses analysis is a part of the safety management system.


Safety Management Safety Management SystemSystem

Safety Regulatory Safety Regulatory SystemSystem

OwnershipOwnership of the of the KnowledgeKnowledge

Proprietary / InternalProprietary / Internal Public DomainPublic Domain

Life cycleLife cycle (typical revision (typical revision time)time)

1 year or less1 year or less 10 years or more10 years or more

ScopeScope A single firmA single firm An entire industryAn entire industry

Based on-Based on- Risk Based,Risk Based,DeductiveDeductive

Experience Based, Experience Based, PrescriptivePrescriptive

StructureStructure (reciprocal links (reciprocal links among single rules in the among single rules in the system)system)

Strong, Strong, HierarchicalHierarchical

Weak, Weak, Layered,Layered,

Not conflicting each-otherNot conflicting each-other

RatificationRatification Internal Approval by theInternal Approval by theduty-holderduty-holder

Sanctioned by Authorities or Sanctioned by Authorities or by Experts Committees by Experts Committees

ControlControl Internal AuditsInternal Audits Regulatory Inspections Regulatory Inspections PenaltiesPenalties


A DUAL SYSTEMA DUAL SYSTEM

As the internal safety management system and the external As the internal safety management system and the external safety regulation system are definitely different, the safety regulation system are definitely different, the problem of finding and reviving the knowledge about problem of finding and reviving the knowledge about safety has been divided in two separate issues:safety has been divided in two separate issues:

• i) Retrieve knowledge by i) Retrieve knowledge by walking troughwalking trough the Safety the Safety Management System (including Safety assessment) of Management System (including Safety assessment) of the single firm.the single firm.

• ii) Retrieve knowledge by ii) Retrieve knowledge by browsingbrowsing in the public in the public Regulation system, in the technical documentation, and Regulation system, in the technical documentation, and in the experience repository.in the experience repository.


Section 1 The Knowledge Inside the EstablishmentSection 1 The Knowledge Inside the Establishment

• NOCE (NO_Conforming Events) NOCE (NO_Conforming Events) a proprietary software.a proprietary software.• The system starts from the mandatory documents and The system starts from the mandatory documents and

looks for the knowledge which may be relevant to the looks for the knowledge which may be relevant to the near miss and to the item involved.near miss and to the item involved.

• the analysis of the event on the light of the safety the analysis of the event on the light of the safety documentation; documentation;

• if the event is linked to a chain leading to a top event, it if the event is linked to a chain leading to a top event, it will be noticed. will be noticed.

• If the component, which the event is related to, has not If the component, which the event is related to, has not direct link to the safety documents, its parent assembly direct link to the safety documents, its parent assembly or unit will be considered. or unit will be considered.


Safety digital representationSafety digital representation • Equipment Equipment digital digital

representation + representation + Digital safety Digital safety

documents + linkdocuments + link

• Equipment Equipment digitaldigital

representationrepresentation is is the backbone of the backbone of

the system.the system.

• Plant scrutiny, Plant scrutiny, according the according the

Mond Idex may Mond Idex may be exploited.be exploited.


List of top events

List of top events

EventEvent

Accidental sequence

Accidental sequence

unitunit

FacilityFacility

AccessoryAccessory

Mond IndexMond Index

PenalityPenality

CreditCredit

ComponentComponent

Emergency Plan

Emergency Plan

Emergency Action

Emergency Action


List of top events

List of top events

EventEvent

Accidental sequence

Accidental sequence

Emergency Plan

Emergency Plan

Emergency Action

Emergency Action

Inspection Plan

Inspection Plan

InspectionInspection

OperatingManual

OperatingManual

Operating ProcedureOperating Procedure

ActionAction

unitunit

FacilityFacility

AccessoryAccessory


PenalityPenality

CreditCredit

ComponentComponent


List of top events

List of top events

EventEvent

Accidental sequence

Accidental sequence

Emergency Plan

Emergency Plan

OperatingManual

OperatingManual

Inspection Plan

Inspection Plan

Emergency Action

Emergency Action

Operating ProcedureOperating Procedure

InspectionInspection

ActionAction

unitunit

FacilityFacility

AccessoryAccessory


PenalityPenality

CreditCredit

ComponentComponent


NOCENOCE

NOCE exploits the “plant safety” digital representation, for:NOCE exploits the “plant safety” digital representation, for:• reporting and analyzing near-misses. reporting and analyzing near-misses. • Updating safety documents, according to the operational Updating safety documents, according to the operational

experience. experience.

• For the digital equipment representation, no extra duties For the digital equipment representation, no extra duties are required; but safety documents have to be exploited are required; but safety documents have to be exploited in a smarter way.in a smarter way.


Section 2 The vs. Knowledge on DemandSection 2 The vs. Knowledge on Demand

• The formal knowledge is mainly unstructured. It is The formal knowledge is mainly unstructured. It is distributed in technical - regulatory documents, distributed in technical - regulatory documents,

• Which include regulations, standard codes, guidelines, Which include regulations, standard codes, guidelines, good practices, manufacturers manuals, safety alerts, good practices, manufacturers manuals, safety alerts,

• Organizing these documents is too difficult job for an Organizing these documents is too difficult job for an individual firm. It is a job for an industrial association (or individual firm. It is a job for an industrial association (or consortium or occupational safety and health agencies) consortium or occupational safety and health agencies)


Taxonomy vs OntologyTaxonomy vs Ontology

• A taxonomy is able only to give a location to each document.A taxonomy is able only to give a location to each document.• An analytical decomposition and a synthetic recomposition of any An analytical decomposition and a synthetic recomposition of any

item are always possible using an “ontology”,item are always possible using an “ontology”,• A ontology provide a schema to put tags in the documents and to A ontology provide a schema to put tags in the documents and to

retrieve them trough a search engine.retrieve them trough a search engine.• The ontology of the “safety measures”The ontology of the “safety measures”

firefitghting

PPEm

ater

ials

proce

sses

activ

ities

proceduresinstruments

equipmentfirefigthingPPE

materials

processes

activitiesprocedures

instruments

equipment


An exampleAn example

• The search is done through the concept which associates the The search is done through the concept which associates the substance ( e.g. substance ( e.g. fuming sulphuric acidfuming sulphuric acid) and the event () and the event (corrosioncorrosion). ). Many affecting issues may be found, but the operator evaluates Many affecting issues may be found, but the operator evaluates which one is appropriate to the case. In the example, the critical which one is appropriate to the case. In the example, the critical factor considered has been the presence of humidity, which factor considered has been the presence of humidity, which accelerates the corrosion. Detailing the problem has the advantage accelerates the corrosion. Detailing the problem has the advantage to focus the search to find solutions through a few concepts. In the to focus the search to find solutions through a few concepts. In the example, the search query is reduced to look for “example, the search query is reduced to look for “how to remove the how to remove the cause humiditycause humidity”, and then which technical measure can be adopted.”, and then which technical measure can be adopted.

• That specific solution represents a That specific solution represents a sleepingsleeping knowledge, since it is a knowledge, since it is a solution already available, but not yet considered inside the solution already available, but not yet considered inside the establishment.establishment.


CONCLUSIONS (1)CONCLUSIONS (1)

NOCE is a software for finding the knowledge hidden in the NOCE is a software for finding the knowledge hidden in the internal documents. It may be used by duty holders. It internal documents. It may be used by duty holders. It requires two items:requires two items:

1)1) a safety management system structured according to a a safety management system structured according to a defined standard (e.g. BS 18001/2007)defined standard (e.g. BS 18001/2007)

2)2) a digital representation of the plant equipment.a digital representation of the plant equipment.

The analysis has been developed for the establishments The analysis has been developed for the establishments where the Major Accident Legislation is enforced. where the Major Accident Legislation is enforced.

The solution, could be transferred to the establishments The solution, could be transferred to the establishments where Major Accident Hazard Legislation is not enforced, where Major Accident Hazard Legislation is not enforced, but where a safety management system, including an but where a safety management system, including an adequate risk evaluation, is present.adequate risk evaluation, is present.


CONCLUSIONS (2)CONCLUSIONS (2)

The presented version of the engine for finding the The presented version of the engine for finding the knowledge hidden in the public documents has been knowledge hidden in the public documents has been developed for the ISPESL local network (featuring some developed for the ISPESL local network (featuring some forty departements and offices, spraded in Italy)forty departements and offices, spraded in Italy)

The proposed method, is adequate to be implemented by The proposed method, is adequate to be implemented by an industrial associations, or by an industrial consortium, an industrial associations, or by an industrial consortium, or by a corporate.or by a corporate.


The study of near misses and the The study of near misses and the knowledge management in mature knowledge management in mature industriesindustries

Patrizia Agnello, Silvia Ansaldi, Paolo A. Bragatto, Paolo PittiglioPatrizia Agnello, Silvia Ansaldi, Paolo A. Bragatto, Paolo Pittiglio

ISPESL - Italian Institute for Occupational Safety and PreventionISPESL - Italian Institute for Occupational Safety and PreventionVia Fontana Candida 1 – Monteporzio Catone (Roma) – 00040 ItalyVia Fontana Candida 1 – Monteporzio Catone (Roma) – 00040 Italy

Contact author: Contact author: [email protected]@ispesl.it

Thanks for your attention! Thanks for your attention! Grazie!Grazie!

asse bragatto 24_feb_10

Health & Medicine

safety system

knowledge management

safety assessment

safety documentation

occupational safety

safety policy

safety alert

digital safety documents