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S a f e t y S t r a t e g i e s

W O R M

The software tool The software tool STORYBUILDER STORYBUILDER and the analysis of the horrible and the analysis of the horrible stories of occupational accidentsstories of occupational accidents

Dr Linda J. Bellamy White Queen, NL

Ir. Martijn Mud, RPS Advies, NL

Martin Damen, RIGO Research & Consultancy

Ir. Hans Baksteen, RIVM, NL

Vanessa van Eijk, Consumer Safety Institute, NL

Marjolijne Samwell, Consumer Safety Institute, NL Prof. Dr Ben Ale TU Delft, NL

Dr. Julius Y. Whiston, WCL Ltd, UK Prof. Andrew R, Hale, TU Delft, NL

Dr Ioannis A. Papazoglou, Demokritos, GR

Anneke Bloemhoff, Consumer Safety Institute, NL

ir. Joy I.H. Oh, Ministry of Social Affairs, NL

1NVVK WORKSHOP

Nov 2006

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HELP!!HELP!!

• Software help manual but misses thingsSoftware help manual but misses things

• Tell us about bugs and problemsTell us about bugs and problems

• Tell us about what you like and future wishesTell us about what you like and future wishes

• Updates/support from us (limited at the moment)Updates/support from us (limited at the moment)

OFFICIAL CONTACT POINT: OFFICIAL CONTACT POINT: arbeidsveiligheid@minszw.nlarbeidsveiligheid@minszw.nl

HOME OF THE STORYBUILDERS:HOME OF THE STORYBUILDERS:

www.storybuilder.euwww.storybuilder.eu

DIRECT CONTACT WITH THE EXPERTS DIRECT CONTACT WITH THE EXPERTS

help@storybuilder.euhelp@storybuilder.eu

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S a f e t y S t r a t e g i e sW O R M

35 STORYBUILDS35 STORYBUILDS

• 35 FILES, 1 MISSING (FALLING OBJECTS, CRANE RELATED)35 FILES, 1 MISSING (FALLING OBJECTS, CRANE RELATED)

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What is storybuilder?What is storybuilder?

• Developed for WORM project –

• Workgroup Occupational Risk Model

• ORM models practically all occupational risks

• ORM needs accident and exposure data

• Storybuilder is a graphical based tool developed specially for WORM

• Captures and represent accident sequence events of ALL occupational accident types

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• 12500 detailed accident reports of 12500 detailed accident reports of Dutch Labour Inspectorate Dutch Labour Inspectorate

• 1998 – Feb 20041998 – Feb 2004

• Reportable under the Dutch law:Reportable under the Dutch law:• Death (within 1 year), permanent Death (within 1 year), permanent

injury, in-patient treatment in injury, in-patient treatment in hospital within 24 hours. hospital within 24 hours.

• Around 10,000 accidents modelled Around 10,000 accidents modelled in 35 Storybuildsin 35 Storybuilds

• Some storybuilds contain more Some storybuilds contain more than 1000 accidents than 1000 accidents

• e.g. fall from ladder has 1057 e.g. fall from ladder has 1057 scenarios with 1061 victimsscenarios with 1061 victims

• 5 person years of effort5 person years of effort

1 CEFall from ladder/steps or stairs

1057 [1061]

Horrible StoriesHorrible Stories

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Storybuilds made01.1.1 Fall from height - ladder & steps

01.1.2 Fall from height – scaffold

01.1.3 Fall from height - roof/platform/floor

01.1.4 Fall from height - hole in the ground

01.1.5.1 Fall from height - moveable platform

01.1.5.2 Fall from height - non-moving vehicle

01.1.5.3 Fall from height - other

01.2 Fall on same level

01.3 Fall down stairs or ramp

02 Struck by moving vehicle

03.1 Contact with falling object – crane related

03.2 Contact with falling objects –not cranes

04 Contact with flying object

05 Hit by rolling/sliding object or person

06 Contact with object person is carrying or using

07 Contact with hand held tools operated by self

08.1 Contact with moving parts of a machine

08.2 Contact with hanging/ swinging objects

08.3 Trapped between/against

09 Moving into an object

10 Buried by bulk mass

11 In or on moving vehicle with loss of control

12 Contact with electricity

13 Contact with extreme hot or cold surfaces or open flame

14.1 Release of hazardous substance out of open containment

14.2 Exposure to hazardous substance without Loss of Containment

15 Release of a hazardous substance out of closed containment

17 Fire

20.1 Victim of human aggression

20.2 Victim of animal behaviour

22.1 Exposure to hazardous atmosphere in confined space

22.2 Exposure to hazardous atmosphere through breathing apparatus

23 Impact by immersion in liquid

25 Extreme muscular exertion

27 Explosion

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Storybuilder functionalityStorybuilder functionality

• Captures detailed cause and Captures detailed cause and effect data effect data

• Shows: Shows:

• storiesstories

• structurestructure

• frequenciesfrequencies

• Gives flexibility to the builder Gives flexibility to the builder and to the analystand to the analyst

1 CEFall from scaffol

d

531 [560]83 0_gSecondarySupport Barrier

s

0 [0]

903 0_BSUUnknownstate for all

barriers in this

15 [16]

904 1_BFMScaffoldprotection

failure: scaffold

11 [12]

178 2_BFMFailure offoundation/ sup

port

18 [19]

170 3_BFMDeficientanchoring or

fixation

114 [130]

173 LCE_1Scaffold

stability fails

107 [123]

164 4_BFMUserProtection

Failure: user hit

22 [23]

181 5_BFMBalance failure

219 [221]

184 LCE_2User stability

fails

377 [381]

151 6_BFMScaffold floor

deficiency

73 [75]

156 7_BFMEdgeprotection failur

e

172 [174]

145 8_BFMScaffoldstructure notsufficient for

54 [63]

154 LCE_3Scaffold

strength fails

38 [46]

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Early versionEarly version

• Building rulesBuilding rules

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Factors affectingConditional Probabilities

Being in rough seaAttention

Personal protectionOverloading

Rhythm of workHurrying (time pressures)

Tidiness of boatsRadio

Type of fishSeaworthiness of boat

INHERENT HAZARDS

Slippery surfacesMoving equipmentBoat movements

Working with hooks and knives

Why: The challenge of smart cod

CONSEQUENCES

DrowningBroken legs

Squashed fingersCut hands

Hook in eyeContaminated cut

W O R M

We want data on…We want data on…

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Evolution to current version:Evolution to current version:• We built in functions We built in functions

required by project required by project e.g.e.g.

• coding, coding, • export/ import,export/ import,• double count double count

prevention (path prevention (path can only pass once can only pass once through a box)through a box)

• ..and functions ..and functions requested by builders requested by builders e.g. e.g.

• scaling, scaling, • fonts, fonts, • path search, path search, • copy and paste,copy and paste,• move…move…

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It now looks like this:It now looks like this:

Path names

Graphical structure with paths

Path search (Boolean syntax) through structure

Data export

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Left hand side (zoom out, collapsed structure)Left hand side (zoom out, collapsed structure)

1 CE

Fall from scaffold

531 [560]

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Right hand side (zoom out, collapsed structure)Right hand side (zoom out, collapsed structure)

1 CE

Fall from scaffold

531 [560]

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Complete structure showing single pathComplete structure showing single path

1 CE

Fall from scaffold

531 [560]

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Building Codes and Rules (1)Building Codes and Rules (1)• Every box has a name, a box number and a codeEvery box has a name, a box number and a code

E.g.E.g.

• Barrier failure mode (BFM)Barrier failure mode (BFM)

• Loss of control event (LCE)Loss of control event (LCE)

• Dose determing factor (DDF)Dose determing factor (DDF)

• Injury type (INJT)Injury type (INJT)

310 LCE

Tool slips

1049 DDF

Wood

288 BFMEquipment state

failure

37 (1) INJ T020 Bone fractures

315 [316]

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Building Codes and Rules (2)Building Codes and Rules (2)

• GROUND RULE: GROUND RULE: No assumptions shall be No assumptions shall be made with respect to any Barrier state or Loss made with respect to any Barrier state or Loss of Control Event. of Control Event.

• Only what is specified in the report should be Only what is specified in the report should be specified in the accident Storybuilds specified in the accident Storybuilds

• Rule 6 Rule 6 If the Loss of Control Event (LCE) occurs the If the Loss of Control Event (LCE) occurs the associated barrier is in the failed state. If a associated barrier is in the failed state. If a barrier is given in the failed state one of the barrier is given in the failed state one of the associated LCE's has to occur. associated LCE's has to occur.

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Example definition: BarrierExample definition: Barrier• Definition 3:Definition 3:

• A barrier is a physical entity (object, state, or condition) that acts A barrier is a physical entity (object, state, or condition) that acts as an obstacle in an accident path. Note that actions can not be as an obstacle in an accident path. Note that actions can not be barriers. Actions can create a barrier or restore its functionality.barriers. Actions can create a barrier or restore its functionality.

• Typical Barrier Functions are:Typical Barrier Functions are:• Prevent presence, build-up, or release of the hazardous agent/ Prevent presence, build-up, or release of the hazardous agent/

energyenergy• Separates hazardous agent/ energy in space (safe distance) or Separates hazardous agent/ energy in space (safe distance) or

time (safe moment)time (safe moment)• Prevents the undesired transmission of energy/ hazardous agents Prevents the undesired transmission of energy/ hazardous agents • Prevents incompatibility of materialsPrevents incompatibility of materials• Prevents unsafe process conditions (pertains to sequence, Prevents unsafe process conditions (pertains to sequence,

temperature, pressure, composition)temperature, pressure, composition)• Prevents unsafe physical conditions (pertains to structural Prevents unsafe physical conditions (pertains to structural

integrity, strength, stability)integrity, strength, stability)

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Example of Storybuilding rule for allocating an accident to a Example of Storybuilding rule for allocating an accident to a barrier taskbarrier task

Was the barrier provided?

PROVIDE No

Yes

Was the provided barrier maintained?

MAINTAIN

USE Was the provided barrier used?

Yes

No Was the main cause that the state of the barrier should have been monitored?

No

MONITOR

Yes

No

Yes

Select other barrier failure!

UNKNOWN

?

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Building the structureBuilding the structure

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Causes and countsCauses and countsFall on

same level

417 [ 417]

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Right hand side of centre eventRight hand side of centre event

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Further detail – Management of machine guardingFurther detail – Management of machine guarding

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Incidental factorsIncidental factors

98 BFMLoss of grip onsurface/ floor

155 [155]

114 (2) IFSlippery

items integrated in floor/ e.g. grating

5 [5]

115 (2) IF

Slope

6 [6]

112 (2) IFloose objects

6 [6]

106 (2) IFShoe related factor

8 [8]

111 (2) IF

Ice, snow

18 [18]

102 (2) IF

Wet floor

85 [85]

3 G

Tasks Group

0 [0]4 G

ManagementDelivery Systems

GROUP

0 [0]

54 (1) DS

Unknown

57 [57]

46 (1) DSPlans and

procedures

14 [14]

47 (1) DS

Availability

0 [0]

52 (1) DS

Competence

0 [0]

53 (1) DSCommunication/collaboration

0 [0]

50 (1) DSConflict resolution

6 [6]

51 (1) DSMotivation/commit

ment

59 [59]

49 (1) DSErgonomics/ MMI

6 [6]

48 (1) DSEquipment

(tools, spares,parts)

23 [23]

55 (1) T

Provide

68 [68]

64 (1) TOperate (Use)

41 [41]

66 (1) T

Maintain

6 [6]

68 (1) T

Monitoring

1 [1]

69 (1) T

Unknown

44 [44]

101 LCE

Slip

155 [155]

98 BFMLoss of grip onsurface/ floor

155 [155]

114 (2) IFSlippery

items integrated in floor/ e.g. grating

5 [5]

115 (2) IF

Slope

6 [6]

112 (2) IFloose objects

6 [6]

106 (2) IFShoe related factor

8 [8]

111 (2) IF

Ice, snow

18 [18]

102 (2) IF

Wet floor

85 [85]

3 G

Tasks Group

0 [0]4 G

ManagementDelivery Systems

GROUP

0 [0]

54 (1) DS

Unknown

57 [57]

46 (1) DSPlans and

procedures

14 [14]

47 (1) DS

Availability

0 [0]

52 (1) DS

Competence

0 [0]

53 (1) DSCommunication/collaboration

0 [0]

50 (1) DSConflict resolution

6 [6]

51 (1) DSMotivation/commit

ment

59 [59]

49 (1) DSErgonomics/ MMI

6 [6]

48 (1) DSEquipment

(tools, spares,parts)

23 [23]

55 (1) T

Provide

68 [68]

64 (1) TOperate (Use)

41 [41]

66 (1) T

Maintain

6 [6]

68 (1) T

Monitoring

1 [1]

69 (1) T

Unknown

44 [44]

101 LCE

Slip

155 [155]

As much detail as possible is captured

e.g. Here are factors which may have contributed to loss of grip causing a person to slip

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Following one horrible story (Fire)Following one horrible story (Fire)Contaminated overalls catch fire

Sequence Name17, 37, 47, 52, 16, 70, 15, 77, 81, 83, 88, 89, 91, 98, 101, 108, 13, 4, 143, 144, 148, 150, 145, 146, 3, 2, 538, 545, 543, 537, 551, 573, 571, 534, 535, 486, 489, 490, 485, 497, 503, 502, 481, 482, 525, 1, 686, 688, 1017, 1058, 689, 693, 691, 813, 812, 705, 702, 806, 809, 803, 690, 793, 707, 770, 768, 773, 771, 781, 779, 746, 748, 747, 743, 712, 715, 714, 730, 716, 725

GISAI-210000539

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Causal sequenceBox Code Name

37 G Working with combustibles, flammables or oxidants

47 AInstallation / Repair/ Decomissioning of gas installations/ flammable equipment

52 INFORepairing unstartable car: inspecting petrol supply (other employee starts motor)

16 G Employment characteristics of victim

70 GEN Employee

15 G Characteristics of Initiating fire

81 CoIF Fibers and textiles

83 CoIF Flammable and combustible liquids

89 CoIF Air

98 CoIF Electrical heat

108 CoIF Electrical equipment/ installations

4 G Equipment Type group

148 ET ESAW 05.01.02 Rotating electric machines, electric motors

150 ET Starting motor (of van)

145 ET ESAW 05.01.01 Thermal engines

146 ET Petrol supply hose

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..cont. to centre event (Fire)..cont. to centre event (Fire)Box Code Name

538 G Management Delivery Systems group

545 15_DS Motivation/ Commitment

543 15_DS Conflict resolution

551 15_T Operate (Use)

571 15_IF System not in adequately safe state (before start of activity)

534 15_BFM Loss of containment

573 15_INFO Petrol squeezes out of supply hose when starting motor for first time

535 LCE Formation of flammable liquid, atmosphere or dust layer

489 8_DS Motivation/ Commitment

490 8_DS Competence

497 8_T Maintain

503 8_INFO Person wears dirty, greasy overall, victim does not change overall

502 8_IF Prone to catch fire

481 8_BFM Clothing failure

482 LCE Clothing catches fire

573 INFO On restarting the motor the jet flame ignites the overalls

525 PSB- Failure of preventing a combustible/ flammable source to be present

1 CE Fire

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RHS Dose determining factorsRHS Dose determining factors Box Code Name

1017 33_BSM Rapid removal of burning/ contaminated clothes

1058 35_BSM Rapid and adequate provision of first aid

693 DDF Exposure time: t < 1 min

813 DDF Distance Source-victim: <= 1m

806 DDF Flame contact : Jet flame/ Jet fire

809 DDF Burning clothes

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ConsequencesConsequences

Box Code Name

793 INJN Number of casualties: N of C = 1

768 INJP 20 Neck, not further specified

771 INJP 30 Back, including spine and vertebra in the back

781 INJP 52 Arm, including elbow

746 INJT 2nd degree burns

748 INJT 3rd degree burns

715 HOSP H = Hospitalised

716 G Injury severity/ duration

725 ABS Injury severity/ duration: 1 month <absence <= 6 months

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Path search functionPath search function• In order to analyze the structures Storybuilder has path search and path In order to analyze the structures Storybuilder has path search and path

export functionality which makes it easier to analyze the data export functionality which makes it easier to analyze the data

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Statistics Statistics

• Can be generated for path search selectionsCan be generated for path search selections

• Or for complete storybuildOr for complete storybuild

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Exported data: example Exported data: example Victim activities for contact moving parts of fixed machineVictim activities for contact moving parts of fixed machine

120UnknownA317

241OtherA322

4150Passing by/ standing atA316

7412Maintaining/ modifying a machineA315

12672Cleaning a machineA314

201075Clearing/ Releasing/ unblockingA313

171400Operating a machine:unknownA1-1(2)

280Operating a machine:Starting up/ shutting down machine

A1-13

10480Operating a machineTesting / tuning/ checking

A1-15

15591Operating a machine:Adjusting / removing a PRODUCT

A1-16

9800Operatinga machine: FeedingA1-14

533351Operating a machine (all)A12

Recoverableinjuries

Permanent injuries

DeathsNameCodeBox

120UnknownA317

241OtherA322

4150Passing by/ standing atA316

7412Maintaining/ modifying a machineA315

12672Cleaning a machineA314

201075Clearing/ Releasing/ unblockingA313

171400Operating a machine:unknownA1-1(2)

280Operating a machine:Starting up/ shutting down machine

A1-13

10480Operating a machineTesting / tuning/ checking

A1-15

15591Operating a machine:Adjusting / removing a PRODUCT

A1-16

9800Operatinga machine: FeedingA1-14

533351Operating a machine (all)A12

Recoverableinjuries

Permanent injuries

DeathsNameCodeBox

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How have the data been used?How have the data been used?

• In the ORM model to assist in defining In the ORM model to assist in defining logical structureslogical structures

• For the accident component in the risk For the accident component in the risk calculationcalculation

• To generate previously unavailable facts To generate previously unavailable facts and figures data on causes and effects of and figures data on causes and effects of occupational accidentsoccupational accidents

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SummarySummary

• Storybuilds capture ALL known causes Storybuilds capture ALL known causes of Dutch reportable accidentsof Dutch reportable accidents

• The models can assist in understanding The models can assist in understanding how "horrible stories" occurhow "horrible stories" occur

• The models can be used for identifying The models can be used for identifying the dominant conditions which give rise the dominant conditions which give rise to accidents to accidents

• Policy makers, inspectors and company Policy makers, inspectors and company safety personnel can use these safety personnel can use these structures in e.g. accident investigation structures in e.g. accident investigation

• Coupled with ORM a powerful tool for Coupled with ORM a powerful tool for understanding occupational risksunderstanding occupational risks