Dr. Sabhashini Ganapathy of Wright State University evaluated the potential to utilize public databases to identify human factors issues in the industry. The database from the Chemical Safety Board was examined and found to show over 40% of the incidents had a human error component. However, poor categorization of the root causes prevented identification of specific human performance shaping factors that contributed to the event.
What are primary categories and their relative rankings for operator (human) actions identified as contributing to serious catastrophic events in the Oil, Gas, and Chemical industries based on publicly available incident databases and reports?
There is a report done by the European Commission JRC Scientific and Policy Reports organization, “Safety of offshore oil and gas operations: Lessons from past accident analysis” that has identified Human Causes of accidents in the WOAD (World Offshore Accident Databank) to consist of 44% Unsafe Action or No Procedure, 37% Unsafe Procedure, 9% third party error, 8% improper design, 1% war or sabotage, and 1% other. Similar results may be expected for the process industries, but a quick review did not provide a comparable study. The US Chemical Safety Board (www.csb.gov) has a database of incident reports that include US based chemical and refining accidents in a variety of categories. It would be good background information for the COP to know if the identified human contributions that are identified in any of those reports fall into the same categories and frequency as the EU JRC report, or if the CSB findings give a significantly different result.
The results can aid the COP to focus future efforts. Similar results would allow a key focus on procedures; what makes a good procedure, tools for generating procedures (continuation of procedure “chunking” project), change management of procedures, wireless access to procedure (continuation of handheld project), etc. Far differing results could lead to creating a focus in some other area of study and identify that procedures may not need to be a focus.
The deliverables for this project will include a detailed report on data associated with incident reports on catastrophic events and will also include data related to classification, categorization of incidents, and frequencies of occurrences for each category with supporting background information. The report will be in a format (.doc and .xls) such that it would be easy to pull the information based on certain category. The report will be easy to read and access and would include information presentation such as drop down and mapping using simple add-ins. A verbal presentation summarizing the findings will also be provided.