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Learning From Organizational Incidents: Resilience Engineering for High-Risk Process Environments

Huber, Stefanie; van Wijgerden, Ivette; de Witt, Arjan and Dekker, Sidney LU (2009) In Process Safety Progress 28(1). p.90-95
Abstract
For years, safety improvements have been made by evaluating incident reports and analyzing errors and violations. Current developments in safety science, however, challenge the idea that safety can meaning-fully be be seen as the absence of errors or other negatives. Instead, the question becomes whether a company is aware of positive ways in which people, at all level of the organisation, contribute to the management and containment of the risks it actually faces. The question, too, is whether the organization has the adaptive capacity necessary to respond to the changing nature of risk as operations shift and evolve. This article presents the results of a resilience engineering safety audit conducted on a chemical company site. An... (More)
For years, safety improvements have been made by evaluating incident reports and analyzing errors and violations. Current developments in safety science, however, challenge the idea that safety can meaning-fully be be seen as the absence of errors or other negatives. Instead, the question becomes whether a company is aware of positive ways in which people, at all level of the organisation, contribute to the management and containment of the risks it actually faces. The question, too, is whether the organization has the adaptive capacity necessary to respond to the changing nature of risk as operations shift and evolve. This article presents the results of a resilience engineering safety audit conducted on a chemical company site. An interdisciplinary team of seven researchers carried out 4 days of field studies and interviews in several plants on this site. This company enjoyed an almost incident-free recent history but turned out to be ill-equiped to handle future risks and many well-known daily problems. Safety was often borrowed from to meet acute production goals. Organizational learning from incidents was fragmented into small organization or production units without a company-wide learning. We conclude that improving safety performance hinges on an organization's dynamic capacity to reflect on and modify its models of risk as operations and insight into them evolve, for example, as they are embodied in safety procedures and policies. (C) 2008 American Institute of Chemical Engineers Process Saf Prog 28: 90-95, 2009 (Less)
Please use this url to cite or link to this publication:
author
organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
incident reporting, chemical industry, anticipation, resilience engineering, hazards, accidents
in
Process Safety Progress
volume
28
issue
1
pages
90 - 95
publisher
John Wiley & Sons
external identifiers
  • wos:000263660100012
  • scopus:64149093240
ISSN
1547-5913
DOI
10.1002/prs.10286
language
English
LU publication?
yes
id
15a065d0-58de-4937-b159-4e7792f67713 (old id 1370887)
date added to LUP
2009-05-08 15:10:27
date last changed
2017-09-17 04:53:34
@article{15a065d0-58de-4937-b159-4e7792f67713,
  abstract     = {For years, safety improvements have been made by evaluating incident reports and analyzing errors and violations. Current developments in safety science, however, challenge the idea that safety can meaning-fully be be seen as the absence of errors or other negatives. Instead, the question becomes whether a company is aware of positive ways in which people, at all level of the organisation, contribute to the management and containment of the risks it actually faces. The question, too, is whether the organization has the adaptive capacity necessary to respond to the changing nature of risk as operations shift and evolve. This article presents the results of a resilience engineering safety audit conducted on a chemical company site. An interdisciplinary team of seven researchers carried out 4 days of field studies and interviews in several plants on this site. This company enjoyed an almost incident-free recent history but turned out to be ill-equiped to handle future risks and many well-known daily problems. Safety was often borrowed from to meet acute production goals. Organizational learning from incidents was fragmented into small organization or production units without a company-wide learning. We conclude that improving safety performance hinges on an organization's dynamic capacity to reflect on and modify its models of risk as operations and insight into them evolve, for example, as they are embodied in safety procedures and policies. (C) 2008 American Institute of Chemical Engineers Process Saf Prog 28: 90-95, 2009},
  author       = {Huber, Stefanie and van Wijgerden, Ivette and de Witt, Arjan and Dekker, Sidney},
  issn         = {1547-5913},
  keyword      = {incident reporting,chemical industry,anticipation,resilience engineering,hazards,accidents},
  language     = {eng},
  number       = {1},
  pages        = {90--95},
  publisher    = {John Wiley & Sons},
  series       = {Process Safety Progress},
  title        = {Learning From Organizational Incidents: Resilience Engineering for High-Risk Process Environments},
  url          = {http://dx.doi.org/10.1002/prs.10286},
  volume       = {28},
  year         = {2009},
}