Ragnar Rosness

Risk Influence Analysis A methodology for identification and assessment of risk reduction strategies

Abstract This article describes Risk Influence Analysis, a methodology for the identification and assessment of risk reduction strategies in large-scale distributed systems such as transportation systems. The approach focuses on the identification of risk-influencing factors, i.e. sets of relatively stable conditions influencing the risk level. Risk reduction strategies are defined by sets of actions designed to change the state of risk-influencing factors. The expected effects of risk reduction strategies are evaluated by expert judgement supported by available data for the analysis object. Quality issues concerning the relevance and trustworthiness of the Risk Influence Analysis methodology are identified. The most important threats to the trustworthiness of the analysis are believed to be: (1) inadequate validity of expert judgements in estimating the effects of risk reduction strategies; and (2) incompleteness of the qualitative analysis results.

Prospective sensemaking in the operating theatre

This paper reports a study of sensemaking in operating theatres. We explored the role of sensemaking processes in the safe and efficient performance of surgical procedures. The study is based on observations, semi-structured interviews, and informal conversations with surgeons, anaesthetists, operating nurses, and anaesthetic nurses. We found that the members of the operating team paid great attention to what might happen during the next seconds, minutes, and hours. They thus built a capacity for anticipation which enabled them to collaborate smoothly and prepared them to handle undesired but foreseeable occurrences. According to Karl Weick, organisational sensemaking is retrospective in the sense that we make sense of our actions and experience after they have occurred. However, our findings suggest that prospective sensemaking is a precondition for safe and successful completion of surgical procedures. Instead of waiting for things to happen and making sense of them in retrospect, the operating team constructed plausible projections of what might happen and how they might handle such plausible futures. Prospective sensemaking is thus less event-driven than retrospective sensemaking. We argue that safe and efficient performance of surgical procedures depends on the quality of prospective sensemaking. We comment on how technology (including procedures) can support prospective sensemaking. Finally, we discuss the relationships between “prospective sensemaking” and related terms, such as “heedful interrelating”, “mindfulness”, “situation awareness”, and “anticipatory thinking”.

Cross border railway operations: improving safety at cultural interfaces

Organizations with different cultures will interface with each other as legislation is introduced to ensure the interoperability of railway systems across Europe. To approach the safety challenges related to interfaces between cultures, the International Union of Railways (UIC) initiated the project Safety Culture at Interfaces. The project covers the development of a method for assessing and trying to improve safety cultural interfaces. The project was performed by SINTEF. This paper presents the method, which is called SafeCulture. The project has piloted the method in three railway organizations with positive evaluations from the participants, identifying several issues that could improve safety at interfaces. It is not possible to isolate safety culture at interfaces from the whole system, embracing environment, infrastructure, organization, individual and teamwork. Safety culture at interfaces is an integrated part of the “whole picture”. Building safety culture at interfaces has been seen as a learning process that requires involvement and commitment between organizations. This is a difficult challenge. One of the first challenges is to motivate and get involvement from the relevant parties in the process. The next challenge is to develop real commitment from the organizations that are involved to agree on common solutions. Our approach to these challenges has been to establish a qualitative method, consisting of questionnaires and exploration of scenarios where the involved parties feel confident of their knowledge and can be motivated to share experience. Involvement and participation from the workforce and management, from the beginning of the learning loop, will create ownership and commitment to the problems and their solutions.

HSE Petroleum: Change — Organisation — Technology

The paper presents the results and main conclusions from a pilot study on technological and organisational changes with a bearing on health and safety conditions in the oil industry. The study applies a cross-disciplinary approach, and focuses specially on human and organisational defences against accident risks, and the importance of workers participation in change processes and discourse arenas for the main stakeholders at different levels on issues regarding facts, means and ends in health and safety management.

Human and Organizational Contributions to Safety Defences in Offshore Oil Production

Offshore petroleum production involves several major hazards. In the tightly coupled production systems, incidents such as gas releases can quickly escalate to major accidents. The industry meets this challenge by introducing various safety defences such as firewalls, emergency shutdown systems, and work permit systems to make the platforms fault tolerant, i.e., to ensure that technical and human failures will not result in incidents or accidents. In high-risk industries the attitude to humans as part of the safety defences has traditionally been sceptic. Humans are perceived to be error prone, and it has generally been seen as desirable to minimize and control humans’ contribution to the extent possible using automation and operating procedures, respectively. In this paper we will argue that humans are essential as part of the safety defences at petroleum installations. Humans’ contributions are of particular importance in situations where the tasks required to defend safety cannot be automated, i.e. reliably accounted for in algorithms, because humans furnish required flexibility into the safety defences. To contribute positively to safety, i.e., in ways that lead to a reduction in the risk level, individuals and work groups need to be supported by appropriate organizational means, such as adequate knowledge, competence, resources, and tools. For this reason, we will refer to defences in which humans are allocated tasks to contribute to plant safety as human and organizational defences. In the paper we will outline three ways in which human and organizational defences are applied at petroleum installations, and discuss what kind of means that are needed to support these types of defences. The paper is based on the outcome of the first part of a research activity on fault tolerance, barriers and resilience [1, 2], which is performed within the framework of the project “HSE Petroleum: Change — Organization — Technology [3]. The issues presented in this paper will be addressed in more details in the following parts of this project.

Limits to Analysis and Verification

The term ‘complexity’ covers a wide variety of system attributes in everyday language. It may refer to the number of subsystems or components, the dynamics of component or subsystems behavior, the number of possible interactions, the presence of non-linear interactions, difficulties in identifying and understanding a system’s interactions with its environment, the impact of human judgment and actions, or even our lack of familiarity with the system. We will not give a rigorous definition of complexity here. A workable approximation may be to state that complexity is a function of the number and properties of the dependencies (intentional and unintentional) which exist between the items of a system and between a system and its environment (adapted from Mancini, 1988).

Identifying safety challenges related to major change processes

In this paper we have tried to identify the main safety challenges in a major change processes. We have explored actual large‐scale changes during deregulation of aviation and rail, and we have explored large‐scale changes in the oil and gas industry. Based on the main safety challenges we have tried to develop a framework to assess the safety of a general change process. The framework consists of key issues to be discussed among the actors involved in the change process. The actors are operators (management and workforce), safety authorities and suppliers. The use of the framework should help assess the status of the change process. We are suggesting that the status of the change process can be categorized as satisfactory (continue), not satisfactory (adjust but continue with caution) or unacceptable (halt, major adjustments must be implemented). The status of the change process can be evaluated prior to the change and during the change. The evaluation of the change prior to the change could be used as a proactive/leading indicator of the change process. The framework is going to be used in several large change processes to gather more experience and to validate and verify the framework

From Incidents to Proactive Actions: A Bottom-up Approach to Identification of Safety Critical Functions

The paper presents a bottom-up approach to identification and follow-up of a set of safety critical functions in railway traffic control. A’ safety critical function’ (SCF) is a function/ task that will increase the personnel risk if it fails. We applied the approach using investigated incidents as a starting point. The work was accomplished in collaboration with an analysis group representing different positions and a diversity of local operating conditions in railway traffic control. The approach may complement a top-down approach using risk analysis as a basis for risk control.

Risikobasert tilsyn i de nordiske arbeidstilsynene

Alle arbeidstilsyn i Norden arbeider ut fra en uttalt risikobasert tilnaerming. For a na denne malsetningen er det nodvendig med en metodikk som er i stand til a identifisere risikoutsatte virksomhe ...

The diversity of systemic safety drift: the role of infrastructure in the railway sector

The paper is motivated by a concern that the “drift” metaphor may trigger stereotyped responses to accidents such as recurring requirements for better change management. The paper explores the idea that mechanisms of drift may be system-dependent by providing a qualitative analysis of the role of infrastructure in accidents and incidents in the Norwegian railway sector. An analysis of five public investigation reports on railway accidents and incidents led to the identification of four mechanisms by which infrastructure may be involved in systemic safety drift. (1) Different infrastructure generations live side by side, leading to operational complexity and less than optimal combinations of technology. (2) Operational complexity, loss of technical barriers, and increased dependence on human performance occurs when railways revert to more basic operating modes due to infrastructure breakdown or modification or maintenance work. (3) Development of infrastructure can lag behind capacity demands, causing human adaptations with implications for safety. (4) The high cost of infrastructure investments and slow funding can cause a lag in resolving safety issues and weaken the motivation for raising concerns or reporting safety incidents. A comparison between main line operations and shunting operations showed that there is considerable variety in the preconditions for drift within the railway sector. It is concluded that attention to the diversity of drift may be a starting point for tailoring safety management strategies and preventive measures to the specific challenges and opportunities of a particular sociotechnical system.