BENCHMARKING ON EPSC MEMBER COMPANY INCIDENT REPORTING SYSTEMS Simon Jones, Manager EPSC Operations 165-179 Railway Terrace, Rugby, CV21 3HQ, UK SUMMARY The European Process Safety Centre (EPSC) has carried out a benchmarking exercise on the incident reporting systems used by EPSC member companies. This has resulted in the creation of a template internal incident report form which is offered for use by any company setting up its own incident reporting system. During this exercise, it was recognised that near-miss reporting was key to improving safety performance. This paper discusses the importance of near-miss-reporting, the features of incident report forms, and how lessons are learned from incidents in the chemical industry. INTRODUCTION The European Process Safety Centre (EPSC) is an international industry-funded organisation which exists to provide an independent technical focus for process safety in Europe. Representatives from our 44 member companies meet regularly to share information amongst themselves, and in this way learn from each other with the goal of improving still further the safety performance of the European Chemical Industry. EPSC s activities are directed towards four principal objectives: 1. Information provide a forum for discussion of best practices on various technical process safety-related topics amongst our members. 2. Research and Development to act as a catalyst in stimulating the required European technical process safety R&D for the identified needs of European process industries. 3. Legislation and Regulations EPSC plays a key role in providing independent technical support in process safety to the European Commission s safety-related legislation. 4. Education and Training provide a source of training information for educating students on safety and loss prevention, and also for related training and continuing education at all levels within the work-force. One group of members the Incident Data Working Party has recently focused on how EPSC member companies collect incident data and use it within their own companies.
EPSC BENCH-MARKING EXERCISE Members of EPSC Incident Data Working Party have carried out a bench-marking exercise on the incident reporting systems individual companies use. The information shared came from the following companies and organisations: Air Products plc; Arco Chemical Europe Inc; BASF plc; Bayer AG; Borealis; BP; Ciba Speciality Chemicals; DNV; Du Pont; European Commission - DG JRC (MAHB); Exxon Chemical Europe; Hoechst Marion Roussel; ICI; Novartis; Norsk Hydro; Rohm & Haas; Rhône-Poulenc; and Norsk Hydro. It was clear from this exercise that no two incident reporting systems were alike. Attention focused instead on what the common elements of incident report forms are, and members also examined some of the more novel elements which some systems try to gather data for. It was decided to compile a template incident report form which would which is offered for internal use by any company who may be planning to implement an incident reporting system. Companies who already have such systems in place may like to compare their own system with the one proposed. The EPSC working party members recognised that the key to improving safety performance within their companies still further lay in the collection and learning lessons from near-miss incidents. This was reflected in the shifting emphasis from collecting statutory occupational accident information only to encouraging reporting on incidents based on their potential consequence. NEAR-MISS REPORTING Near-miss incidents can usefully be defined as those hazardous situations, events or unsafe acts that occur where the sequence of events could have caused an accident if it had not been interrupted. If it is accepted that near-misses however minor do occur on a large facility every week, then this represents a large pool of data which could be collected and learned from. Definitions are important to understanding the terms widely used in industry when talking about incidents, and are also important when considering European legislation: Major accident - as defined by the Seveso II Directive 1 Accident - an undesirable event resulting in injury or damage. Major near-miss - a hazardous situation where planned safety systems have proved inadequate or ineffective and the consequences of which could reasonably be expected to lead to a major accident had he sequence of events not been interrupted by other means. A learning experience for the purposes of the Seveso II Directive. Near-miss - a hazardous situation, event or unsafe act where the sequence of events could have caused an accident if it had not been interrupted. Incident - all undesired events, including accidents and near-misses. Direct cause - the immediate reason why an incident occurred. Usually consisting of unsafe conditions at the site or unsafe acts by a person. Root cause - the factors in the system which allow the direct cause to arise. A failure in the safety management system. Removing the root cause will stop the accident being repeated.
It is clear that incidents have an economic impact on business. Studies 2 have indicated that for every 1 of insured cost associated with an incident, there are between 8 and 36 of hidden and uninsured costs. It is good business practice to collect information on incidents that have occurred and learn from them in order not to repeat mistakes. The European Chemical Industry has had successful safety management systems 3 in place which, amongst other things, have facilitated this for some time. These systems have led to a long period of continuous improvement in safety performance and therefore reductions in the numbers of accidents. A more recent trend is to collect information on near-misses that occur on facilities. Many companies now have an increase in the number of near-misses reported specified as a positive indicator of performance. This is to stimulate near-miss reporting and in recognition that more near-misses occur than are reported presently. See reference 4 for a discussion of other safety performance indicators. It has been demonstrated in various studies 5,6,7, that there is a relationship between the numbers of near-misses, minor incidents and major accidents. This can be shown as a triangle 5 : Importance of near-miss data 1 10 30 Major injury Minor injury Property damage 600 Near-misses The exact figures vary from study to study, but the crucial thing to recognise is that reducing the number of near-misses that occur reduces the number that proceed to become full accidents, with more severe human and economic impact. This then, is the goal of near-miss reporting: to stimulate near-miss reporting and learn lessons from them in order to reduce near-miss occurrences. This will lead to a further reduction in accidents and an improvement in safety performance. This concept has been demonstrated to be effective in practice at EPSC member company Norsk Hydro 8. In the late 1980 s in Norsk Hydro s offshore industry, line leaders were encouraged to stimulate near-miss reporting and try to learn more from those that were reported. This increased awareness lead to an apparent increase in nearmiss occurrences, however at the same time, this increased awareness also lead to a reduction in accidents. This finding lead to similar techniques being adopted in the company s on-shore activities, with a similar positive results. THE PROPOSED INTERNAL INCIDENT REPORT FORM
The actual reporting forms used to gather incident and near-miss data in EPSC member companies have been analysed and three key types have been identified: 1. Notification form. A simple form filled in by anyone on the site to inform of incidents or dangerous occurrences. This has a key role in generating the near-miss information. 2. Preliminary analysis/investigation form 3. Company report, communicating the issues raised and lessons learned from the accident throughout the company. Analysis of the notification and preliminary analysis forms which EPSC member companies use has led to the creation of a template incident report form, which is offered for internal use by any company who may be planning to implement an incident reporting system. Companies who already have such systems in place may like to compare their own system with the one proposed. If the goal of a company is to stimulate near-miss reporting, then any form to gather data must be fairly simple to complete by all levels of staff within a manufacturing facility. The proposed form appears in appendix 1 of this paper. The first page of the report is designed to be fairly simple to complete. Individuals may be able to contribute to the completion of the second page. Their supervisor/manager can then complete the form and ensure further actions and communications take place. In this way it is hoped that near-misses reporting may be stimulated. Once near-misses are being reported, and lessons are learned from them, it is expected that the frequency of their occurrence will start to decrease. Classifying incidents It is a concern that once a near-miss reporting system is up and running, it may become swamped by seemingly trivial near-miss reports. Whilst it is recognised that every nearmiss is a potential learning experience for a company, in reality some method of prioritising and directing the resources available is usually required. In many EPSC companies this is achieved by assessing some measure of the potential of the near-miss, and ensuring that the level of follow-up and investigation is commensurate with the potential consequence and/or likelihood of reoccurrence. The first three sections of the report form in appendix 1 deal with describing the incident adequately. A classification system for what constitutes a MAJOR, SERIOUS and MINOR incident would need to developed by the company using the system. This can be seen as a consequence based approach to classifying the incident effect or potential. Resources could then be directed by the company according to an incident s actual or potential consequences. Several EPSC member companies classify incident in terms of both potential consequences and likelihood of reoccurrence. This leads to a risk management-type approach using a risk matrix to analyse the incident. Under such a scheme, an incident s actual consequences, or a judgement of the potential consequences, would typically be assigned one of four categories, based consideration of the impact or potential impact upon:
health and safety the public the environment money losses Similarly, a probability category is assigned, based on a judgement aided by linking a quantitative or qualitative description of probability or frequency to several categories. These consequence and probability categories can be mapped onto a matrix to decide if the incident was high H, medium M or low l potential risk: Probability Consequence A B C D 1 H H H M 2 H H M M 3 H M M l 4 M l l l Some member companies incorporate such risk matrices into their incident reporting systems to ensure that the degree of follow-up and investigation of the incident is commensurate with the actual or potential risk. Direct causes Section 4 of the report form in appendix 1deals with direct causes which describe the immediate reason for the incident. Classically, these are split into Unsafe Conditions (existing at site) and Unsafe Acts (by personnel). Typical unsafe conditions include: control system/safeguard failures alarm insufficient ergonomics factors inadequate design/construction/manufacture chemical reaction incorrect material, etc Typical unsafe acts include: operating instruction/permit not followed wrong equipment used PPE not worn failure to isolate, etc Several tools are available to help in the identification of the important direct causes. For minor near-misses, that is those incidents with low potential consequences or potential risks, it may be sufficient to use such check-lists to identify the immediate causes. For high potential, or complex process incidents, then full investigation may be triggered, using the information gathered on the form in appendix 2 as a starting point.
Root causes Sections 7 & 8 deal with the root causes of the incident and their classification as safety management system failures. It can be argued that all incidents are the result of some management system failure. The key is to identify in each case where the safety management system has not functioned correctly. Several tools are used to help this analysis. For minor near-misses it may be sufficient for the manager or supervisor to identify and record the management system which is relevant to the direct cause. For more significant incidents, check-lists, trees and classifications of root-causes have been developed. Different companies use different root cause analysis tools, however a common goal is to record these findings so that changes can be made to prevent the particular incident, and all similar such incidents reoccurring. When reviewing collections of incidents for root causes, a profile of common causes may be identified. This may also be true of the direct causes. Such common cause analysis is a powerful aid to direct management attention and focus. Computerised accident data collection programmes can help in the process of reporting, tracking actions to close out, recording direct and root causes to incident, and producing such common causal analysis. Many companies have developed such internal systems. HOW TO USE THE LESSONS LEARNED? Once this data is gathered, it is vital that the lessons that can be learned from them are circulated widely. Companies must have systems in place to disseminate this information to all those that may be affected. This is performed by various methods in member companies, and, increasingly, through harnessing information technology. It is important that the lessons learned from significant individual incidents, along with common causal data is usefully used. It is vital that these lessons are used to make appropriate changes to relevant management systems and to the implementation of those systems and practices. Examples of areas for consideration include making changes, based on these lessons learned, to: operating instructions; hazard awareness in personnel; management practices; elements of the safety management system; engineering design guidelines/standards; the chemicals that are developed for production (inherent safety). It is good engineering practice to consider sharing the lessons learned information outside your company, in order that incidents are not repeated. Many organisations facilitate this, including:
German chemical industry initiative where German Chemical Industry Association (VCI) facilitates the sharing of near-miss incidents with the German Major Hazards Committee (SFK) via a DECHEMA expert committee. Institution of Chemical Engineers have published a journal of case-studies of incidents since the mid-1970 s, the Loss Prevention Bulletin. More recently this Institution has developed its own Accident Database. Specific international industry organisations provide a forum at which to share experiences, e.g EPSC, IPSG and various industry sector groups. MARS - voluntary contributions to MARS are encouraged under the SEVESO II Directive. CONCLUSIONS Companies can learn from their near-misses without having to suffer the consequences of a full accident. Focusing on the reduction of near-miss occurrences, through stimulating near-miss reporting, has been shown to reduce frequency of accidents. A template incident report form, based on a benchmarking exercise amongst EPSC member companies, is offered for internal use by any company who may be planning to implement an incident reporting system. Companies who already have such systems in place may like to compare their own system with the one proposed. Use of the incident reporting system to learn lessons from significant accidents, coupled with common-cause analysis of collections of incidents can usefully be used to direct safety programmes and make changes to management systems and their implementation. Sharing lessons from incidents widely is the key to further safety performance improvement in European Industry.
REFERENCES 1. European Union Council Directive 96/82/EEC of 9 December 1996 on the control of major-accident hazards involving dangerous substances. 2. Health and Safety Executive, The Costs of Accidents at Work, 1993, HMSO, London, ISBN 0 11 886374 6 3. Safety Management Systems - Sharing experiences in process safety, EPSC, 1994, ISBN 0 85295 356 9 4. Safety Performance Measurement, EPSC, 1996, ISBN 0 85295 382 8 5. Bird, FE and Germain G L, Damage Control, 1966, American Management Assoc. Inc., New York 6. Heinrich, H W, Industrial accident prevention: a safety management approach, 5th Ed., 1980, ISBN 0 07 028061 4 7. Tye, J, Accident ratio study, 1974/75, British Safety Council, London, 1976 8. Jones S, Kirchsteiger C, Bjerke W, The importance of near miss reporting to further improve safety performance, to be published (end 1998/early 1999), Journal of Loss Prevention.
Incident number: APPENDIX 1 EPSC INCIDENT REPORTING SYSTEM Page 1: INCIDENT NOTIFICATION form for use by all staff 1. CLASS OF INCIDENT: Accident Near miss 2. INCIDENT CHARACTER: Injury Damage Material loss Fire/explosion Environment Transportation Other 3. DETAILS OF INCIDENT: Plant / location: Time: Operating state: Normal operation Maintenance Start-up Shut-down Process upset Construction Brief description of the equipment involved / activity being carried out, and its normal function: Description of incident: Severity of consequences or potential consequences: MAJOR SERIOUS MINOR Damage Production loss Personnel injury Environmental Type and quantity of material released: 4. DIRECT CAUSES: describe the immediate reason for the incident Unsafe conditions (existing at site) Unsafe acts (by personnel) How often did the process step / equipment work properly? (an estimate of frequency): 5. IMMEDIATE CORRECTIVE ACTIONS TAKEN:
EPSC INCIDENT REPORTING SYSTEM Page 2: PRELIMINARY ANALYSIS/INVESTIGATION FORM 6. IS THE INCIDENT NOTIFIABLE TO THE AUTHORITIES? YES NO 7. ROOT CAUSES OF ACCIDENT: describe the factors which allowed the direct cause to arise: 8. CLASSIFICATION OF ROOT CAUSES / SAFETY MANAGEMENT SYSTEM FAILURES: check Adequacy of Elements: check Adequacy of Elements: Procedures Management of change Standards Pre start-up review Design Process hazard study Audit Process safety information Inspection & test Training / instruction 9. RECOMMENDATIONS / FURTHER ACTION Full incident investigation required? YES NO Preventative actions Person Deadline Completed? List separate reports generated: 10. WIDER LESSONS Describe lessons to be learned with respect to root causes, and any new knowledge acquired. Are these new lessons? YES NO Consider who needs to know this information within the company, and within the industry in general.