Human and Organisational Factors in Major Accident Prevention

A Snapshot of the Academic Landscape

by Kate Cox, James Black, Sarah Grand-Clement, Alexandra Hall

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Research Questions

  1. How have academic approaches to major accident causation changed over time?
  2. What factors can contribute to effective major accident prevention?
  3. What factors can impede effective major accident prevention?
  4. How does academic thinking on human and organisational factors translate to industry practice?

Health, safety and the environment is a priority area for high reliability organisations (HROs), yet the past 30 years have seen various major accidents including Piper Alpha (1988) and Fukushima (2011). While HROs initially focused on the technical factors causing major accidents, there is increasing recognition of human and organisational factors (HOF) as an important issue. The relevance of near misses and critical incidents is particularly important: for these organisations, even apparently insignificant errors can combine to pose a major threat to organisations, individuals, and the environment.

However, there appears to be limited academic coverage of the initiatives implemented to prevent such accidents. In recognition of this gap, RAND Europe was commissioned by TOTAL E&P Research and Development to conduct research into academic and industry approaches to HOF in major accident prevention. The resulting report focuses on a core element of this study, which examines the body of academic work on HOF in major accident causation and prevention.

In the wider study, this analysis provided the foundation for subsequent work, namely the identification of lessons from the nuclear and aviation sectors and an examination of oil and gas sector approaches to major accident prevention. However, the published report focuses exclusively on the academic landscape and does not include an analysis of industry approaches. It is intended to provide a brief introduction to HOF approaches in academia and should be of interest to industry professionals seeking to build or strengthen academic partnerships, as well as academics specialising in human factors research.

Key Findings

Based on insights from academic experts and literature, the report finds that:

  • Accidents are no longer considered to be caused by a single 'chain of events'.
  • Academics have departed from the view that accidents are caused by a single chain of events, with each accident causing the next.
  • Accident causation is now seen as less linear and more complex.

Academic focus has shifted from 'human error' to 'human and organisational factors'.

  • Early accident analyses have attributed industrial disasters, such as Three Mile Island, Bhopal and Chernobyl, to operator error.
  • While 'human error' theory remains influential — with studies attributing 80 per cent of accidents to individuals' mistakes — there is now a broader understanding of human and organisational factors affecting system safety.

The literature highlights 'good practices' and implementation challenges in accident prevention.

  • 'Good practices' include adopting a 'no-blame' approach to error management, establishing a reporting culture and providing training tailored to the specific HOF challenges faced by an organisation.
  • Nonetheless, economic pressures, regulatory constraints and cultural limitations can impede major accident prevention efforts.

Despite barriers to implementing academic work, academic research translates to industry practice in several ways.

  • While productive partnerships have been formed between academia and industry, much of the academic knowledge in the HOF domain is too abstract to have practical applicability,
  • Models of academia-industry engagement include conferences, publications, academia-industry working groups, joint research programmes and analytical tools for industry based on academic work.

Recommendations

Building on the issues and challenges identified by the report, the following recommendations were developed for human factors experts in industry and academia:

  • A standardised HOF taxonomy should be developed for the oil and gas sector, drawing on both industrial and academic inputs.
  • An accessible overview of HOF theories and trends over time should be developed for the oil and gas sector.
  • Oil and gas sector companies should continue to develop effective engagement models in partnership with universities and research institutes.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    Insights from academia

  • Chapter Three

    Conclusions and recommendations

  • Appendix A

    Technical approach

  • Appendix B

    Glossary

  • Appendix C

    Interview protocol

  • Appendix D

    List of interviewees

  • Appendix E

    Literature review search strategy

Research conducted by

The research described in this report was prepared for TOTAL E&P Research and Development and conducted by RAND Europe.

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