Identifying pan-industry common contributors to major accident events
Joelle Mitchell A B and Alice Turnbull AA NOPSEMA, 58 Mounts Bay Road, Perth, WA 6000, Australia.
B Corresponding author. Email: joelle.mitchell@nopsema.gov.au
The APPEA Journal 60(1) 41-52 https://doi.org/10.1071/AJ19036
Submitted: 6 December 2019 Accepted: 14 February 2020 Published: 15 May 2020
Abstract
Analysis of incident investigation findings as a means of identifying common precursors or causal factors is a common topic of safety research. Historically this type of research has been conducted through a single lens, depending on the researcher’s discipline, with incidents analysed in accordance with a favoured theory, or grouped according to industry or region. This has led to the development of numerous frameworks and taxonomies that attempt to predict or analyse events at various levels of granularity. Such theories and disciplines include safety culture and climate, human factors, human error, management systems, systems theory, engineering and design, chemistry and maintenance. The intent of such research is ostensibly to assist organisations in understanding the degree to which their operations are vulnerable to known precursors or causal factors to major accident events and to take proactive measures to improve the safety of their operations. However, the discipline-specific nature of much of this research may limit its application in practice. Specific frameworks and taxonomies may be of assistance when organisations have identified a relevant area of vulnerability within their operations, but are unlikely to assist organisations in identifying those vulnerabilities in the first place. This paper seeks to fill that gap. A multidisciplinary approach was taken to identify common causal factors. Investigation reports published by independent investigation agencies across various industries were analysed to determine common causal factors regardless of discipline or industry.
Keywords: accident prevention, common causal factors, human factors, incident investigation, MAE, safety, safety management system, systems theory.
Joelle Mitchell is an Organisational Psychologist and human factors specialist, and is the Human Factors Technical Officer for NOPSEMA (National Offshore Petroleum Safety and Environmental Management Authority). She applies the principles of evidence-based practice to facilitate improvement in safety outcomes within NOPSEMA’s compliance and improvement activities. Joelle has worked internally for petroleum companies and as a consultant to the onshore mining industry. Joelle is a Fellow of the Australian Psychological Society College of Organisational Psychologists. Her qualifications include a BSc (Honours) and a Master of Applied Psychology. |
Alice Turnbull is currently the Strategic Compliance Manager at NOPSEMA. With tertiary qualifications as an environmental engineer (EEng (Honours)) and scientist (BSc), Alice’s career has evolved from consulting and regulating in the environment arena, with a focus on environmental and social impact assessment and environmental risk management, to a broader, strategic and multidisciplinary role on strategic risk management and regulation across fields as diverse as process safety, well integrity and environmental management. |
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