Impact of Societal Norms on Safety, Health, and the Environment E-Book

Lee T. Ostrom

• Herausgeber: John Wiley & Sons
• Kategorie: Wissenschaft und neue Technologien
• Sprache: Englisch

Seitenzahl: 1214

Veröffentlichungsjahr: 2022

Beschreibung

A compelling exploration of how social norms and commercial culture impact the safety of organizational operations In Impact of Societal Norms on Safety, Health, and the Environment: Case Studies in Society and Safety Culture, distinguished engineer Dr. Lee T. Ostrom delivers an authoritative treatment of the cultural, social, and human factors of safety cultures and issues in the workplace. The book offers readers compelling discussions of how those factors impact organizational operations and what contributes to making those impacts beneficial or detrimental. The author provides numerous real-world case studies from North America and Europe that are relevant to a global audience, highlighting the central message of the book: that an organization that views its safety culture as unimportant could be setting itself up for a significant workplace accident. Readers will also find: * A thorough introduction to social norms that impact how commercial organizations treat issues of safety and workplace health * In-depth safety culture case studies from North America and Europe * Comprehensive explorations of how peoples' perceptions of hazards impact workplace operations and the daily lives of employees * Fulsome discussions of the effect of societal attitudes on workplace health and safety Perfect for industrial and safety managers, safety coordinators, and safety representatives, Impact of Societal Norms on Safety, Health, and the Environment will also earn a place in the libraries of industrial hygienists, ergonomic program coordinators, and HR professionals.

Leseprobe

Table of Contents

Cover

Title Page

Copyright

Preface

Abbreviations

1 Safety Culture Concepts

1.0 Introduction

1.1 Culture

1.2 Safety and Health Pioneers

1.3 The Evolution of Accident Causation Models

1.4 Safety and Common Sense

1.5 Interviews with Safety Professionals

1.6 Chapter Summary

References

2 History of Safety Culture

2.1 Life Expectancy and Safety

2.2 Consumer Items and Toys

2.3 Flawed Cars

2.4 Ford Pinto

2.5 Off‐Highway‐Vehicle‐Related Fatalities Reported

2.6 Work Relationships

2.7 Food

2.8 Genetically Modified Organisms (GMO) Foods

2.9 Traffic Safety

2.10 Public Acceptance of Seatbelts and Masks for Protection from Respiratory Disease

2.11 Radiation Hazards and Safety

2.12 The Occupational Safety and Health Administration (OSHA)

2.13 Human Performance Improvement (HPI)

2.14 Chapter Summary

References

3 Chemical Manufacturing

3.0 Introduction

3.1 Process Safety Management

3.2 DuPont La Porte, TX, Methyl Mercaptan Release – November 15, 2014

3.3 BP Texas City Refinery Explosion – March 23, 2005

3.4 T2 Laboratories, Inc. Explosion – December 19, 2007

3.5 Final Thoughts for This Chapter

References

4 Chemical Storage Explosions

4.0 Introduction

4.1 Port of Lebanon – August 4, 2020

4.2 PCA DeRidder Paper Mill Gas System Explosion, DeRidder, Louisiana – February 8, 2017

4.3 West Fertilizer Explosion – April 17, 2013

References

5 Dust Explosions and Entertainment Venue Case Studies

5.0 Introduction

5.1 Dust Explosion Information and Case Studies

5.2 AL Solutions December 9, 2010

5.3 Imperial Sugar Company, February 7, 2008

5.4 Entertainment Venue Case Studies

5.5 Safety Culture Summary

References

6 University Laboratory Accident Case Studies

6.0 Introduction

6.1 My Experience at Aalto University

6.2 Texas Tech University October 2008

6.3 University of California Los Angeles – December 29, 2008

6.4 University of Utah – July 2017

6.5 University of Hawaii – March 16, 2016

References

7 Aviation Case Studies

7.0 Introduction

7.1 Helicopter Accident

7.2 Commercial Aviation

7.3 Illegal Dispatch Contrary to the MEL: Taking Off With Blank Fuel Gauges

7.4 Summary of Safety Culture Issues

7.5 Miracle on the Hudson River – Successful Landing of a Crippled Commercial Airliner 2, January 15, 2009

7.6 737 MAX

7.7 De Haviland Comet

7.8 Summary of Safety Culture Issues

References

8 Nuclear Energy Case Studies

8.0 Introduction

8.1 Nuclear Power

8.2 Nuclear Criticality

8.3 Medical Misadministration of Radioisotopes Events

8.4 Goiania, Brazil Teletherapy Machine Incident (IAEA 1988)

References

9 Other Transportation Case Studies

9.1 Large Marine Vessel Accidents

9.2 Navy Vessel Collisions

9.3 Stretch Duck 7 July 19, 2018

9.4 Recent Railroad Accidents

References

10 Assessing Safety Culture

10.0 Introduction

10.1 Survey Research Principles

10.2 Assessing Health Care Safety Culture

10.3 Seven Steps to Assess Safety Culture

10.4 Chapter Summary

References

Index

End User License Agreement

List of Tables

Chapter 1

Table 1.1 Safety culture policy statement traits.

Chapter 2

Table 2.1 X‐ray spectrometer analysis results of scanning items.

Table 2.2 Examples of GMOs resulting from agricultural biotechnology.

Table 2.3 Motor vehicle traffic fatalities and fatality rates 1899–2019....

Table 2.4 Comparison of the number of fatalities with and without constraint...

Chapter 4

Table 4.1 Chemicals stored at the West Fertilizer Company on April 17, 2013....

Chapter 5

Table 5.1 Examples of

K

st

values for different types of dusts.

Table 5.2 List of compounds with dust explosion potential.

Table 5.3 Listing of dust explosions.

Chapter 6

Table 6.1 List of laboratory accidents.

Table 6.2 Safety concerns on the University of Utah Campus.

Chapter 7

Table 7.1 Aviation accidents that occurred in the United States in January 2...

Table 7.2 Injuries on Flight 1549.

Chapter 8

Table 8.1 Significant events after the TMI accident.

Chapter 9

Table 9.1 Injuries.

Table 9.2 Locomotive event recorder information.

Table 9.3 Operational Tests and Inspections (OTIS) observations completed pe...

Chapter 10

Table 10.1 Healthcare safety culture survey tools.

Table 10.2 Example of Likert scale.

List of Illustrations

Chapter 1

Figure 1.1 Heinrich's theory of accident causation.

Figure 1.2 Heinrich's theory of an accident sequence.

Figure 1.3 Removing a domino in the sequence.

Figure 1.4 Heinrich's triangle.

Figure 1.5 Frank Bird's theory of accident causation.

Figure 1.6 Frank Bird's accident triangle.

Figure 1.7 James Reason's Swiss cheese model.

Figure 1.8 Basic unit of the FRAM model.

Figure 1.9 Example connection in a FRAM model.

Figure 1.10 Representation of the aircraft inspection process.

Figure 1.11 Inspection risk framework.

Figure 1.12 Concept of resiliency. Source: Shane Bush.

Figure 1.13 G‐force simulator.

Figure 1.14 Swedish air force incident trend.

Figure 1.15 Traditional risk management.

Figure 1.16 Example occurrence report form.

Figure 1.17 Occurrence report system.

Figure 1.18 Pilot flies C130 too low in violation of flight rules.

Figure 1.19 Crash site of Norwegian C130J.

Figure 1.20 Gripen aircraft flown by wing commander Åström.

Figure 1.21 Risk/reward graph.

Figure 1.22 Ejection seat handle testing.

Figure 1.23 Reactor oversight framework.

Figure 1.24 ROP action matrix. Source: 2022/United States Nuclear Regulatory...

Chapter 2

Figure 2.1 Northern Pacific Rotary Accident February 11, 1903.

Figure 2.2 Vintage items that were scanned.

Figure 2.3 Native American coin bank being scanner.

Figure 2.4 Scan results for “tin” soldier.

Figure 2.5 Shoe fluoroscope.

Figure 2.6 Nonfatal accident rate, 1972 to 2018.

Chapter 3

Figure 3.1 Chemistry of soap making. Source: Drawing by Ostrom.

Figure 3.2 Lannate® production building.

Figure 3.3 Waste gas vent header.

Figure 3.4 Location of shift supervisor overcome by methyl mercaptan.

Figure 3.5 Locations of operators.

Figure 3.6 Locations of operator 6.

Figure 3.7 Layout of the plant and wind direction.

Figure 3.8 Location of the methyl mercaptan storage tank and pump, in relati...

Figure 3.9 Location of plant in relation to the surrounding communities.

Figure 3.10 Diagram of the plant.

Figure 3.11 Blowdown drum.

Figure 3.12 Diagram of relationship of reflux drum to blowdown drum.

Figure 3.13 Drawing of raffinate process.

Figure 3.14 Remains of the pickup truck.

Figure 3.15 Calculated over pressure wave.

Figure 3.16 Aerial photograph of T2 taken December 20, 2007.

Figure 3.17 Drawing of the reactor.

Figure 3.18 Control room. Source:

Figure 3.19 Injury and business locations.

Figure 3.20 Portion of the 3‐in.‐thick reactor.

Figure 3.21 Agitator Shaft.

Chapter 4

Figure 4.1 Devastation of the Port of Beirut.

Figure 4.2 Approximate location of PEPCON plant.

Figure 4.3 PEPCON explosion.

Figure 4.4 Aftermath of the explosion.

Figure 4.5 PCA DeRidder Plant.

Figure 4.6 Diagram of components of the PCA DeRidder Mill.

Figure 4.7 Diagram 2 of components of PCA DeRidder Mill.

Figure 4.8 Repaired pipe.

Figure 4.9 Layout of the West Fertilizer Company Building.

Figure 4.10 Photos of the West Fertilizer Company Explosion.

Chapter 5

Figure 5.1 Overhead view of the AL Solutions site.

Figure 5.2 Drum of scrap.

Figure 5.3 Flow of milling process.

Figure 5.4 Photo of compacted titanium/zirconium.

Figure 5.5 Locations of operators.

Figure 5.6 Damage inside production area.

Figure 5.7 Scraping on wall of blender.

Figure 5.8 Blender wall.

Figure 5.9 Ceiling above blender.

Figure 5.10 Drums of material.

Figure 5.11 Location of hydrogen sensor.

Figure 5.12 West bucket elevator tower; silos 3, 2, and 1; and south packing...

Figure 5.13 Imperial Sugar facility before the explosion. Granulated sugar s...

Figure 5.14 Packing buildings first floor plan.

Figure 5.15 Silo tunnel and conveyor plan.

Figure 5.16 Granulated sugar supply and discharge through the silos.

Figure 5.17 Granulated sugar steel conveyor belts above the silos, c. 1990. ...

Figure 5.18 Silo tunnel steel conveyor belt.

Figure 5.19 Steel belt covers (arrows) crumpled from an initial dust explosi...

Figure 5.20 Stainless steel cover panels (arrows) blown off the steel belt e...

Figure 5.21 South stairwell brick walls blown into the packing building.

Figure 5.22 Access port inside the pantleg room and steel rod used to break ...

Figure 5.23 Limited clearance between sugar discharge chute and the steel be...

Figure 5.24 Three‐inch thick concrete floor slabs lifted off the steel suppo...

Figure 5.25 Motor cooling fins and fan guard covered with sugar dust; large ...

Figure 5.26 Deep piles of sugar accumulated on floors and equipment. Note sh...

Chapter 6

Figure 6.1 Experimental setup for positron experiment.

Figure 6.2 Dewar of liquid helium.

Figure 6.3 Ambulance fire.

Figure 6.4 Hazards identified in Aalto University Laboratories.

Figure 6.5 Hazards in Aalto University Laboratories that caused injuries....

Figure 6.6 Chemical storage.

Figure 6.7 Lab bench mess.

Figure 6.8 Contaminated eyewash station.

Figure 6.9 Chair blocking eyewash station.

Figure 6.10 Lab coats blocking safety shower.

Figure 6.11 Disabled safety shower still present.

Figure 6.12 Electrical cord draped across eyewash.

Figure 6.13 Burned lab coat.

Figure 6.14 CAES project approval flow (Ostrom 2021).

Chapter 7

Figure 7.1 Very high frequency Omni Range Station.

Figure 7.2 Helicopter involved in the accident.

Figure 7.3 Seating configuration.

Figure 7.4 FAA‐approved exemplar four‐point restraint with rotary buckle; ar...

Figure 7.5 FlyNYON Yellow Harness.

Figure 7.6 Front passenger's tether from the accident flight with top lockin...

Figure 7.7 Screen capture from the safety video shown to the passengers befo...

Figure 7.8 Tether loop near floor mounted controls.

Figure 7.9 Drip stick rendition.

Figure 7.10 Flight track of the airplane.

Figure 7.11 A photograph showing the airplane occupants on the wings and in ...

Chapter 8

Figure 8.1 Experimental breeder reactor 1 building.

Figure 8.2 Interior of experimental breeder reactor 1.

Figure 8.3 Percentage of electricity generated by nuclear power plants.

Figure 8.4 Diagram of a pressure‐water reactor.

Figure 8.5 Diagram of a boiling‐water reactor.

Figure 8.6 Arrangement of the reactor containment building to the cooling to...

Figure 8.7 Aerial view of the sodium reactor complex at Santa Susana.

Figure 8.8 Monju reactor complex.

Figure 8.9 RBMK reactor diagram 1.

Figure 8.10 RBMK diagram 2.

Figure 8.11 Damaged Chernobyl reactor.

Figure 8.12 Reactor and systems at steady state.

Figure 8.13 Pressure relief valve is open, reactor starting to overheat.

Figure 8.14 Fuel is not covered with water and melting.

Figure 8.15 Plan view of the tanks involved in the accident.

Figure 8.16 Elevation view of the tanks involved in the accident.

Figure 8.17 SL‐1 reactor building.

Figure 8.18 Authorized procedure and the procedure that was performed.

Figure 8.19 Omnitron brachytherapy afterloader.

Figure 8.20 Diagram of tractor‐trailer route carrying iridium‐192 source at ...

Figure 8.21 HDR internal mechanism.

Figure 8.22 HDR internal mechanism – 2.

Figure 8.23 Catheter connection plate.

Figure 8.24 Console on the HDR unit.

Figure 8.25 HDR operator console.

Chapter 9

Figure 9.1 Genesis River.

Figure 9.2 Lower Houston Ship Channel profile with navigation beacons as vie...

Figure 9.3 Bayport Flare and turn at Five Mile Cut.

Figure 9.4 Pilot 2 helm orders as Genesis River and BW Oak passed in Bayport...

Figure 9.5 Pilot 2 orders and communications before the collision.

Figure 9.6 Screen capture from wheelhouse video on board the Voyager at the ...

Figure 9.7 Relative size of the USS Fitzgerald.

Figure 9.8 (a, b) Illustration map of approximate collision location.

Figure 9.9 Bridge schematic of FITZGERALD.

Figure 9.10 Diagram of approximate collision geometry.

Figure 9.11 Depiction of a bow and bulbous bow.

Figure 9.12 Starboard side of FITZGERALD. Inset Above: Damage to FITZGERALD ...

Figure 9.13 Commander's stateroom area‐exterior.

Figure 9.14 Commander's stateroom‐interior.

Figure 9.15 Non‐watertight door frame from Berthing 2 to the ladder going up...

Figure 9.16 Berthing 2 layout diagram (facing aft).

Figure 9.17 Sample Berthing 1. Starboard side egress – ladder up.

Figure 9.18 Sample Berthing 2. Starboard side egress – ladder up.

Figure 9.19 Sample Berthing 3. Starboard side egress – scuttle down to forwa...

Figure 9.20 Sample Berthing 2 view from row 3 of racks to the port side (ope...

Figure 9.21 Berthing 2 layout of racks and lockers (facing aft).

Figure 9.22 Relative size of USS JOHN S MCCAIN.

Figure 9.23 (a, b) Illustration map of approximate collision location.

Figure 9.24 Bridge schematic of JOHN S MCCAIN.

Figure 9.25 Illustration of ship control console on JOHN S MCCAIN.

Figure 9.26 Approximate geometry and point of impact between USS JOHN S MCCA...

Figure 9.27 Bulbous bow of ALINIC MC and damage to hull from bow to stern.

Figure 9.28 Point of impact on JOHN S MCCAIN from ALINIC MC.

Figure 9.29 Depiction of approximate location of point of impact.

Figure 9.30 Relative positions of Berthings labelled 3, 5, and 7, is point o...

Figure 9.31 Primary egress from Berthing 5. Left: from within Berthing 5. Ri...

Figure 9.32 Escape scuttle from Berthing 5. Left: From within Berthing 5. Ri...

Figure 9.33 Relative positions of Berthings 3, 5, and 7 and point of impact....

Figure 9.34 Berthing 3 facing port.

Figure 9.35 Berthing 3 facing port after collision.

Figure 9.36 Scuttle and hatch showing the space completely flooded.

Figure 9.37 Berthing 4 dewatering.

Figure 9.38 Port side of JOHN S MCCAIN post‐collision.

Figure 9.39 Closeup of port side damage.

Figure 9.40 Stretch Duck 7 after salvage from Table Rock Lake, July 2018....

Figure 9.41 Miss Majestic post‐salvage, 1999.

Figure 9.42 DUKW in military use before conversion to passenger service.

Figure 9.43 Torn canopy of the Stretch Duck 7 found during recovery operatio...

Figure 9.44 Accident scene.

Figure 9.45 Train 188 intended route.

Figure 9.46 Train 188's route through Philadelphia.

Figure 9.47 Amtrak routes throughout the United States.

Figure 9.48 Montreal, Maine & Atlantic Railway (MMA) map.

Figure 9.49 The Lac‐Mégantic derailment site following the accident.

Figure 9.50 Grade and elevation between Nantes and Megantic.

Figure 9.51 The three locations that were the focal points of the investigat...

Figure 9.52 Eastward view of the location of the tracks in relation to the f...

Figure 9.53 Location of the locomotive consist (Mile 116.41 of the Moosehead...

Figure 9.54 Schematic of the locomotive air brake and hand brake.

Figure 9.55 Hand brake assembly and wheel at the B‐end of a tank car.

Chapter 10

Figure 10.1 Example results of the graduate student safety culture survey.

Guide

Cover

Table of Contents

Title Page

Copyright

Preface

Abbreviations

Begin Reading

Index

End User License Agreement

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Impact of Societal Norms on Safety, Health, and the Environment

Case Studies in Society and Safety Culture

Lee T. Ostrom

University of Idaho Idaho Falls, USA

This edition first published 2023

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Cover Image: © Thatree Thitivongvaroon/Getty Images

Preface

Accidental deaths are the fourth most common cause of death in the United States, claiming approximately 200,000 people each year. Deaths from falls account for approximately 42,000 deaths and deaths from automobile accidents accounts for approximately 40,000 deaths. 4764 fatal occupational injuries occurred in 2020 and this represents the lowest annual number since 2013. A worker died every 111 minutes from a work‐related injury in 2020. Compare this with the approximately 16,000 occupational deaths in 1940. This decrease in the number of deaths is due to the increased focus on safety in workplace and more recently to the concentration on the importance of safety culture in organizations. However, horrific accidents still occur every day. Every organization has a safety culture. There are numerous organizations that have very positive safety cultures and there are many that have very negative safety cultures. This book contains case studies on accidents and the safety culture attributes associated with the events. Please use the descriptions of the safety culture problems in the case studies to help improve your organizations.

Abbreviations

%

percent

°

degrees

°C

degrees celsius

°F

degrees fahrenheit

3D

three‐dimensional

65NJ

Helo Kearny Heliport

AA

aluminum association

AAO

acetaldehyde oxime

AAR

Association of American Railroads (United States)

AAR

Association of American Railroads

AB

able bodied seaman

AC

advisory circular

AC

air conditioning

ACC

American Chemistry Council

agl

Above ground level

AHJ

Authority Having Jurisdiction

AIChE

American Institute of Chemical Engineers

AIS

automatic identification system

AIS

abbreviated injury scale

Amtrak

National Railroad Passenger Corporation

AN

ammonium nitrate

ANFO

ammonium nitrate/fuel oil

ANSI

American National Standards Institute

AP

anterior–posterior

API

American Petroleum Institute

ARA

Agricultural Retailers Association

ARPA

automatic radar plotting aid

ARS

air rescue systems

ARSST

Advanced Reactive System Screening Tool

AS

ammonium sulfate

ASLRRA

American Short Line and Regional Railroad Association (United States)

ASSE

American Society of Safety Engineers

ASTM

American Society for Testing Materials

ATC

air traffic control

ATC

automatic train control

ATF

Bureau of Alcohol, Tobacco, Firearms, and Explosives (United States)

ATT

airframe total time

b/d

barrels per day

BC

borden chemical

BEA

Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile

BFI

Browning‐Ferris Industries

BLET

Brotherhood of Locomotive Engineers and Trainmen

BLEVE

boiling liquid expanding vapor explosion

BOV

bottom outlet valve

BRM

bridge resource management

BRM/BTM

bridge resource management/bridge team management hp

CAL

confirmatory action letter

CalOSHA

California Division of Occupational Safety and Health

CAN

certified nursing assistant

CANUTEC

Canadian Transport Emergency Centre

CCPS

Center for Chemical Process Safety

CCTV

closed circuit television

CDC

Centers for Disease Control and Prevention

CDP

Center for Domestic Preparedness

CDRH

Center for Devices and Radiological health, FDA

CDT

Central Daylight Time

CEO

chief executive officer

CEPP

Chemical Emergency Preparedness Program

CERCLA

Comprehensive Environmental Response, Compensation, and Liability Act

CFATS

Chemical Facility Anti‐Terrorism Standards

CFM

cubic feet per minute

CFR

Code of Federal Regulations (United States)

CMU

concrete masonry unit

CN

Canadian National

CNCG

Concentrated Non‐Condensable Gas

COI

chemical of interest

Conrail

consolidated rail corporation

COO

chief operating officer

CPR

Canadian Pacific Railway

CRM

crew resource management

CROR

Canadian Rail Operating Rules

CSA

Canadian Standards Association

CSAT

Chemical Security Assessment Tool

CSB

Chemical Safety and Hazard Investigation Board (United States)

CSCD

Chemical Security Compliance Division

CT

computed tomography

CTA

Canadian Transportation Agency

CTA

CTA Acoustics, Inc.

CTC

centralized traffic control

CTG

Continuing Training Grant

CTPS

computerized treatment plan

CWR

continuous welded rail

CX

customer experience

DCS

distributed control system

DG

dangerous good

DHS

Department of Homeland Security (United States)

DIERS

Design Institute for Emergency Relief Systems

Diglyme

diethylene glycol (dimethyl) ether

DO

director of operations

DOL

Department of Labor (United States)

DOT

Department of Transportation (United States)

DWC

Division of Workers' Compensation

ECDIS

Electronic Chart Display and Information System

ECP

Electronically Controlled Pneumatic (Braking System)

ECR

engine control room

EDT

eastern daylight time

EHS

extremely hazardous substance

EMPG

Emergency Management Performance Grant

EMS

emergency medical services

EMT

emergency medical technician

EO

executive order

EOC

emergency operations center

EOT

engine order telegraph

EPA

Environmental Protection Agency (United States)

EPCRA

Emergency Planning and Community Right‐to‐Know Act

ERAP

emergency response assistance plan

ERDC

Engineer Research and Development Center

ERG

Emergency Response Guidebook

ERP

Emergency Response Plan

ERT

Emergency Response Team

ESC

Electrostatic Charging Tendency

eTicketing

electronic ticketing

EU

European Union

FAA

Federal Aviation Administration

FAST

firefighter assist and search team

FAST

Fixing America's Surface Transportation

FBU

Fluoroproducts Business Unit

FDA

Food and Drug Administration

FDEP

Florida Department of Environmental Protection

FDNY

Fire Department of the City of New York

FEMA

Federal Emergency Management Agency (United States)

FFCL

fuel flow control lever

FFFIPP

Fire Fighter Fatality Investigation and Prevention Program

FGAN

fertilizer grade ammonium nitrate

FOM

flight operations manual

FOV

field of view

FP&S

Fire Prevention and Safety

fpm

feet per minute

FR

Federal Register

FRA

Federal Railroad Administration (United States)

FRS

Facility Registry Service

FSDO

flight standards district office

FSOL

fuel shutoff lever

g/cm

3

grams per cubic centimeter

GAO

Government Accounting Office

GAO

Government Accountability Office (United States)

GDC

General Duty Clause

GE

General Electric Company

GHS

Globally Harmonized System of Classification and Labeling of Chemicals

GM

General Motors

GMP

Good Manufacturing Practices

GOI

General Operating Instructions

GPCC

Greater Pittsburg Cancer Center

GPD

Grant Programs Directorate

GPN

Graduate Practical Nurse

GRT

gross register tons

GSI

General Special Instructions

HAZCOM

OSHA's Hazard Communication

HAZMAT

hazardous material

HAZOP

Hazard and operability study

HAZWOPER

Hazardous Waste Operations and Emergency Response

HCS

Hazard Communication Standard

HDR

high dose rate

HHC

highly hazardous chemical

HSE

Health and Safety Executive (United Kingdom)

HSNTP

Homeland Security National Training Program

HUD

Department of Housing and Urban Development (United States)

HVAC

heating, ventilation, and air conditioning

HVLC

high volume low concentration

IAFC

International Association of Fire Chiefs

IAFF

International Association of Fire Fighters

IAP

Incident Action Plan

IBC

International Building Code

IC

Incident Commander

ICA

instructions for continued airworthiness

ICAO

International Civil Aviation Organization

ICBO

International Conference of Building Officials

ICC

International Code Council

ICHEME

Institution of Chemical Engineers

ICS

Incident Command System

ICT

Insurance Council of Texas

ICWUC

International Chemical Workers Union Council

IDLH

Immediately Dangerous to Life or Health

IEC

International Electrotechnical Commission

IFC

International Fire Code

IIS

Inspection Information System (TC)

IIT

Incident Investigation Team

IME

Institute of Makers of Explosives

IMIS

Integrated Management Information System

IMO

International Maritime Organization

IOSHA

Indiana Occupational Safety and Health Administration

IP

Inspection Procedure

IRCC

Indiana Regional Cancer Center

Irving

Irving Oil Ltd.

ISA

International Society of Automation

ISO

Insurance Services Office

ISO

International Organization for Standardization

IST

inherently safer technology

JFRD

Jacksonville Fire and Rescue Department

JSO

Jacksonville Sheriff's Office

kip

kilopound (1 kip = 1000 lb)

KJRB

Downtown Manhattan/Wall Street Heliport

km/h

kilometers per hour

K‐Mag

potassium magnesium

KSt

Dust Deflagration Index

kts

knots

kW

kilowatts

KYOSHA

Kentucky Department of Labor, Office of Occupational Safety and health

LE

locomotive engineer

LED

light‐emitting diode

LEL

lower explosive limit (also known as lower flammable limit)

LEP

Local Emphasis Programs

LEPC

Local Emergency Planning Committee

LER

locomotive event recorder

LFL

lower flammable limit (also known as lower explosive limit)

LGA

LaGuardia Airport

LLC

Limited Liability Company

LNG

liquefied natural gas

LOA

letter of authorization

LOC

limiting oxidant (oxygen) concentration

LOPA

Layers of Protection Analysis

LPBC

Local Performance Based Compensation Program

LPG

liquid propane gas

LPN

licensed practical nurse

LS

Lumbar‐Sacral

LVHC

low volume high concentration

m

meters

MACT

Maximum Achievable Control Technology

MARC

Maryland Area Regional Commuter

MAWP

maximum allowable working pressure

MC

manual chapter

MCI

mass casualty incident

MCMT

methylcyclopentadienyl manganese tricarbonyl

MCPD

methylcyclopentadiene

MEC

Minimum Explosive Concentration

MeSH

methyl mercaptan

MG

miscellaneous guidance

MIC MOC

methyl isocyanate management of change

MIE

minimum ignition energy

MIOSHA

Michigan Occupational Safety and Health Administration

MLLW

mean lower low water

mm

millimeters

MMA

Montreal, Maine and Atlantic Railway

MOC

management of change

MOU

memorandum of understanding

MP

milepost

mph

miles per hour

MSDS

Material Safety Data Sheet

msl

mean sea level

NAICS

North American Industry Classification System

NASFM

National Association of State Fire Marshals

NBSR

Southern New Brunswick Southern Railway

NCG

non‐condensable gas

NCOSHA

North Carolina Department of Labor, Occupational Safety and Health Division

NEC

National Electric Code

NEIC

National Earthquake Information Center

NEP

National Emphasis Program

NERRTC

National Emergency Response and Rescue Training Center

NESHAP

National Emissions Standards for Hazardous Air Pollutants

NEW

net explosive weight

NFA

National Fire Academy

NFPA

National Fire Protection Association

NIMS

National Incident Management System

NIOSH

National Institute for Occupational Safety and Health

nm

nautical miles

NMSS

Nuclear Material Safety and Safeguards

NOAA

National Oceanic and Atmospheric Administration OS

NORAC

Northeast Operating Rules Advisory Committee (Operating Rulebook)

NO

X

nitrogen oxide

NPD

National Preparedness Directorate

NPRM

notice of proposed rulemaking

NRC

Nuclear Regulatory Commission

NRC

National Research Council of Canada

NRS

Northwest River Supplies

NTED

National Training and Education Division

NTSB

National Transportation Safety Board (United States)

NVFC

National Volunteer Fire Council

NYC

New York City

NYPD

New York City Police Department

OAG

Office of the Auditor General

OB

Operating Bulletin

OEM

Office of Emergency Management (Philadelphia)

OIG

Office of Inspector General

OpSpec

operations specification

ORIS

Oak Ridge Institute for Sciences and Education

OSC

Oncology Services Corporation

OSH Act

Occupational Safety and Health Act of 1970 (United States)

OSHA

Department of Labor Occupational Safety and Health Administration (United States)

OSHA

Occupational Safety and Health Administration

OSHRC

Occupational Safety and Health Review Commission (United States)

OTI

OSHA Training Institute

OTIS

Operational Tests and Inspections Program

OTSC

Office of the Texas State Chemist

PAI

Permit Authorizing Individual

PAI

principal avionics inspector

PCA

Packaging Corporation of America

PCDS

personnel carrying device system

PDD

proximity detection device

PEL

Permissible exposure limit

PES

programmable Electronic System

PFD

personal flotation device

PFD

Philadelphia Fire Department

PG

packing group

PHA

process hazard analysis

PHMSA

Pipeline and Hazardous Materials Safety Administration (United States)

PHMSA

Pipeline and Hazardous Materials Safety Administration

PIC

pilot‐in‐command

PMI

principal maintenance inspector

POI

principal operations inspector

ppb

parts per billion

PPC

Public Protection Classification

PPD

Philadelphia Police Department

PPE

Personal Protective Equipment

ppm

parts per million

PPU

Portable pilot unit

PRD

pressure relief device

PRV

pressure relief valve

psi

pounds per square inch

PSI

Process Safety Information

psia

pounds per square inch absolute

psig

pound‐force per square inch gauge

psig

pounds per square inch gauge

PSM

OSHA Process Safety Management Standard

PSM

Process Safety Management

PTC

positive train control

PVC

polyvinyl chloride

Q&A

question and answer

QA

quality assurance

QC

quality control

QM

quality management

QNS&L

Quebec North Shore and Labrador Railway

QRB

quick release brake (valve)

QSR

Quebec Southern Railway

RAC

Railway Association of Canada

RAGAGEP

Recognized and Generally Accepted Good Engineering Practice

RBPS

Risk Based Process Safety

RCMS

Responsible Care Management System®

RCRA

Resource Conservation and Recovery Act

RCS

relative culture strength

RDPC

Rural Domestic Preparedness Consortium

REAC/TS

Radiation Emergency Assistance Center/Training Site

REL

recommended exposure limit

RFI

request for information

RFM

rotorcraft flight manual

RFMS

rotorcraft flight manual supplement

RMP

Risk Management Plan Rule

RMR

Reactivity Management Roundtable

RN

registered nurse

RODS

Rail Occurrence Database System (TSB)

rpm

revolutions per minute

RSA

Railway Safety Act

RSC

reset safety control

RSI

railway safety inspector

RSO

Radiation Safety Officer

RTC

rail traffic controller

RTR

Registered Technologist Radiographer

RTT

Registered Therapy Technician

RWI

Rail World, Inc.

S/N

serial number

SAA

State Administrative Agency

SAChE

Safety and Chemical Engineering Education Committee

SAF

Swedish Air Force

SAFER

Staffing for Adequate Fire and Emergency Response

SARA

Superfund Amendments and Reauthorization Act

SB

service bulletin

SBA

Small Business Administration

SBU

sense and braking unit

SCBA

self‐contained breathing apparatus

SCBA

self‐contained breathing apparatus

SD

secure digital

SDS

safety data sheet

SEP

Special Emphasis Programs

SEPTA

Southeastern Pennsylvania Transportation Authority

SERC

State Emergency Response Commission

SFFMA

State Firefighters' and Fire Marshals' Association

SFMO

State Fire Marshal's Office

SHI

Substance Hazards Index

SHIB

Safety and Health Information Bulletin

SHM

Scenery Hill Manner

SIBU

Standard Insecticide Business Unit

SIC

Standard Industry Code

SIC

Standard Industrial Classification

SIS

Safety Instrumented System

SMS

Safety Management System

SMS

Manual Safety Management System

SOLAS

International Convention for the Safety of Life at Sea

SOP

standard operating procedure

SOR

Southern Ontario Railway

SPCC

spill prevention, control, and countermeasures

SPRS

supplemental passenger restraint system

SPTO

single‐person train operations

SQ

Sûreté du Québec

SSO

Safety Systems Overview

SST

Strobel Starostka Transfer, LLC

STC

supplemental type certificate

STD

start‐to‐discharge (pressure)

TAC

Texas Administrative Code

TAPPI

Technical Association of Pulp and Paper Industry

TC

Transport Canada

TCDS

type certificate data sheet

TCEQ

Texas Commission on Environmental Quality

TCFP

Texas Commission on Fire Protection

TDG

transportation of dangerous goods

TDI

Texas Department of Insurance

TEEX

Texas A&M Engineering Extension Service

TFI

The Fertilizer Institute

TGAN

technical grade ammonium nitrate

TIESB

Texas Industrial Emergency Services Board

TIP

Technical Information Paper

TNT

trinitrotoluene

TOPS

Tour Operators Program of Safety

TR

technical report

TRANSCAER

Transportation Community Awareness and Emergency Response

Tranz Rail

Tranz Rail Holdings Limited (New Zealand)

TRI

Toxics Release Inventory

TRS

Total Reduced Sulfur

TSB

Transportation Safety Board of Canada

TSO

technical standard order

TSR

Track Safety Rules

TWA

time‐weighted average

TX

Texas

UK

United Kingdom

UEL

upper explosive limit (also known as upper flammable limit)

UFC

Uniform Fire Code California Division of Occupational Safety and Health

UFCW

United Food and Commercial Workers

UFL

upper flammable limit (also known as upper explosive limit)

UN

United Nations (product code)

UNECE

United Nations Economic

USACE

US Army Corps of Engineers

USC

United States Code

USFA

Fire Administration (United States)

USGS

Geological Survey (United States)

USS

United States Ship

VDR

voyage data recorder

VFD

volunteer fire department

VFR

visual flight rules

VHF

very high frequency

VIA

VIA Rail Canada, Inc.

VSP2

Vent Sizing Package 2

VTS

Vessel traffic service

WC

Wisconsin Central

WFC

West Fertilizer Company

WFD

West Fire Department

WFSI

World Fuel Services, Inc.

WIS

West Intermediate School

WISD

West Independent School District

WMS

West Middle School

WVFD

West Volunteer Fire Department

1Safety Culture Concepts

1.0 Introduction

Summer blockbuster movies always have some huge disaster as a major part of the plot. These events include events like airplanes crashing, volcanoes erupting, explosions, ships sinking, fires, tornadoes, earthquakes, railroad trains crashing, or alien invasions. In the movies all the bloodshed is fake. In reality, these types of disastrous events cause real people to die, to become severely injured and destroy families' homes and businesses. Events like tornadoes, earthquakes, and volcanoes can't be prevented. However, airplanes crashing, industrial explosions, ships sinking, trains crashing, and fires can be prevented. Alien invasions, well we don't know yet (or maybe we do).

Safety and health professionals dedicate their lives trying to prevent people from being killed or injured and to prevent property damage. Safety and health professionals include:

Safety engineers

Industrial hygienists

Fire inspectors

Fire fighters

Health physicist

Radiation safety officers

Ergonomists

Risk analysts

Human factors practitioners

In addition to:

Professional engineers of all types

Chemists

Biologists

Ecologists

Physicists

Medical professionals

Police and Military

It is quite a list of professionals who work to keep us safe. Some of these professionals are dedicated to designing safe products, some to ensuring safe working conditions, some working to ensure we live healthy lives, and some ensuring our physical security.

I wrote this book because of my passion about safety and helping people come home safe every day from work. The case studies in this book represent a broad range of events that have happened and could happen tomorrow, if precautions are not taken. Safety culture is the focus of the book because disastrous events can be prevented if the safety culture of organizations is improved.

The book is organized into 10 chapters. Chapter 1 discusses the concepts of safety culture; Chapter 2 discusses aspects of the evolution of safety and safety culture through the centuries and decades, Chapters 3–9 discuss a wide range of accident case studies and the associated safety culture attributes. Chapter 10 discusses methods of assessing safety culture.

The case studies presented in the book should inspire employers to ensure their facilities and processes are engineered and maintained to be safe, employees are properly trained, and organizations place a high value on the lives of their employees.

I want to thank the investigators form the Chemical Safety Board (CSB), National Transpiration Safety Board (NTBS), Canadian Transportation Safety Board (CTBS), Nuclear Regulatory Commission (NRC), the Department of Energy (DOE), and local fire and police departments for their integrity in performing the detailed accident investigations that I have used in this book.

1.1 Culture

The American Heritage Dictionary defines culture as “The totality of socially transmitted behavior patterns, arts, beliefs, institutions, and all other products of human work and thought characteristic of a community or population.” A culture is comprised of behavioral norms, patterns of perceptions, language/speech, and even building design features that make the culture what it is. It is difficult to understand a culture in total, but it is possible to study and understand individual norms. A social norm is defined as an unspoken rule of behavior that, if not followed, will result in sanctions. In an organization, a norm might be that managers must business attire.

In this organization, a manager who arrives at a meeting in casual clothes might be teased or reprimanded. If he or she consistently failed to wear the appropriate clothing, might be considered unprofessional, not reflecting the company image, and face severe sanctions, including loss of his or her position.

Every organization, as does every country, has a culture. Even within a country, cultures vary widely. The cultures within the United States vary greatly. We all know how different the culture in a northeast state varies from the deep South. Consider also that a city culture varies from a culture just outside a city. We recently watched a movie entitled “Into the White.” The movie was based on a true story about a German and a British air crew stranded in the high Norwegian plateau during World War II after shooting each other down. The interesting part about this movie to me is when they were out of food and starving a British and a German airman went hunting for food. They shot a rabbit and brought it back to their cabin and all five looked at the dead rabbit and had no clue how to prepare it to eat. I grew up in the mountains of the west and I was hunting at 12 and cleaning what I killed. These airmen had been denied that skill because of the cultures they grew up in.

Cultures vary widely in countries and areas within countries. Consider the languages in the small country of Dagestan. The country is only about 20,000 mi2 (about 50,000 km2) and has only 3.1 million residents. There are more than 30 ethnic groups and 81 nationalities. There are 14 official languages, and 12 ethnic groups constituting more than 1% of its total population. In addition, there are over 40 languages (Charles Rivers 2019). So, how did all these cultures come about? Dagestan borders the Caspian Sea and is in the Caucasus Mountains. It was at a crossroads during ancient times and many villages were high in the mountains. Adjacent villages were separated enough that distinct dialects developed. Also, the invasions by various groups brought languages and customs to Dagestan as well.

So, what is the point of this? It is that within companies and organizations safety cultures vary widely, just as cultures range widely in cities, counties, states, and countries.

A safety culture is composed of safety norms within a company or an organization. A safety norm can be positive or negative (Ostrom, Wilhelmsen, and Kaplan 1993). A positive norm is that a lab worker always dons their safety glasses and a fire‐resistant lab coat every time they enter a lab. A negative norm is when an electrician fails to use proper lock and tag procedures when working on electrical circuits. The case studies will present the results of numerous case studies involving negative safety norms.

Pidgeon (1991) writings from 1991 are still true today. He wrote that a “good” safety culture is hard to define. Part of the reason for this is that each organization's culture is somewhat unique. Culture can be influenced by the nation or region, by the technologies and tools it uses, and by the history of success and failure the company/organization has achieved. Safety culture of an organization may be influenced by the marketplace and regulatory setting in which it operates. Safety culture may be influenced by the vision, values, and beliefs of its leaders as well. All these influences make it difficult to say what a “good” safety culture will look like in a particular setting. Despite differences, good safety cultures do have things in common:

Good safety cultures have employees with particular patterns of attitudes toward safety practice.

Because it is impractical to establish formal, explicit rules for all foreseeable hazards, norms within the organization are required to provide guidance in particular circumstances.

In a “good” safety culture employees might be alert for unexpected changes and ask for help when they encounter an unfamiliar hazard.

They would seek and use available information that would improve safety performance. In a “good” safety culture, the organization rewards individuals who call attention to safety problems and who are innovative in finding ways to locate and assess workplace hazards.

All groups in the organization participate in defining and addressing safety concerns, and one group does not impose safety on another in a punitive manner.

Organizations with a “good” safety culture are reflexive on safety practices.

They have mechanisms in place to gather safety‐related information, measure safety performance, and bring people together to learn how to work more safely.

They use these mechanisms not only to support solving immediate safety problems but also to learn how to better identify and address those problems on a day‐to‐day basis.

What is acceptable in a company regarding safety must be defined and practiced if a corporate culture that values safety is to be created. Ideally, employees should know all the risks associated with their jobs, what is required for safety, and take responsibility for themselves. In other words, develop a norm in which employees are aware of all the risks in their workplace or are continually on the lookout for risks.

The result is an overall positive attitude toward safety.

1.2 Safety and Health Pioneers

People have been trying to understand and control the factors that lead to occupational illnesses and accidents for two millennia. Some of the first leaders in occupational safety and health were Hippocrates, Pliny the Elder, Galen, Agricola, and Bernardino Ramazzini. The Greek physician Hippocrates identified lead as a hazardous material in the mining industry in about 400 BCE (BC). He helped develop rules for working in mines. The Roman Pliny the Elder in about 100 CE (AD) identified zinc fumes and sulfur vapors as hazardous. He developed a face mask made from animal bladders to help protect chemical workers. Galen was another Greek physician who characterized the pathology of lead poisoning and the hazards of working copper miners who were exposed to acid mists. Agricola was a German scholar and a very early industrial hygienist and described the diseases of miners. He also developed preventative measures to avoid diseases associated with mining.

Bernardino Ramazzini made a huge impact on safety and health. Most safety and health professionals consider him to be the founder of occupational medicine. Those of us who work also in ergonomics consider him to have been a pioneer in the study of musculoskeletal injuries.

He was born on October 4, 1633, in the small town of Capri. This town is located in the duchy of Modula, Italy. In his lifetime he established the field of occupational medicine. In 1682 Duke Francesco II of Modena assigned him to establish a medical department at the University of Modena. His title was professor “Medicinae Theoricae.”

He was appointed chair of practical medicine in Padua, Republic of Venice, in 1700. This was the premier medical faculty in Italy. That same year he wrote the seminal book on occupational diseases and industrial hygiene, De Morbis Artificum Diatriba (Diseases of Workers).

He is best known for his work on exposure to toxic materials. His pioneering effort in musculoskeletal illnesses included linking occupations to specific disorders (Franco and Fusetti 2004). Ramazzini was one of the first to observe that common musculoskeletal illnesses could develop due to common stresses associated with poor ergonomics, for instance, prolonged stationary postures or of unnatural postures. Just as today, people working in awkward postures like bakers, scribes, weavers, or washer women could develop illnesses. People in professions that required prolonged static postures like workers who stand or are required to sit for long periods of time can develop problems as well. In addition, workers who are required to perform tasks that require heavy muscular performance are at risk of injury.

1.3 The Evolution of Accident Causation Models

The next step in the evolution of safety was the development of accident causation models. Accident causation models have been evolving for about 100 years. Heinrich's Domino Theory developed in the 1930s was based on the premise that a social environment conducive to accidents was the first of five dominos to fall in an accident sequence (Figures 1.1 and 1.2) (Heinrich 1931; Heinrich, Peterson, and Roos 1980). The social environment in this case is associated with the culture the worker grew up in. Included in this were what Heinrich called, ancestry traits, like stubbornness, greed, and recklessness. The other four dominos in sequence were fault of person (personal traits), unsafe acts/mechanical issues/facility, accident, and injury/property damage. If a domino is removed, then the accident sequence is stopped. This theory is now 90‐plus years old and focuses on the inherent traits of the person, instead of all the other cultural influences on safety, within an organization. However, his theory does support the concept that accidents occur because of a sequence of events (Figure 1.3).

Figure 1.1 Heinrich's theory of accident causation.

Source: Redrawn by Ostrom (2022).

Figure 1.2 Heinrich's theory of an accident sequence.

Source: Redrawn by Ostrom (2022).

Heinrich's accident process is:

The environment is where and how a person was raised and educated, therefore the culture of his upbringing.

Faults of persons are inherited or acquired because of their social environment or acquired by ancestry.

Personal and mechanical hazards exist only through the fault of careless persons or poorly designed or improperly maintained equipment.

An accident occurs only because of a personal or mechanical hazards.

A personal injury (the final domino) occurs only because of an accident.

Figure 1.3 Removing a domino in the sequence.

Source: Redrawn by Ostrom (2022).

Heinrich believed that the unsafe act or mechanical/physical hazard should be examined and corrected first to be able to prevent accidents.

A major development in the accident causation process by Heinrich is that an accident is any unplanned, uncontrolled event that could result in personal injury or property damage. For example, if a person gets their hand caught in a piece of equipment an accident has occurred even if no injury resulted. Heinrich developed the initial accident hierarchy triangle (Figure 1.4). This triangle shows his idea of how many near miss accidents there were (300) to minor injury accidents (29) to major injury accidents/deaths (1).

Frank Bird (Bird and Germain 1996) modified the dominos to reflect his theory of accident causation in the late 1960s and early 1970s (Figure 1.5). His ratio of near miss accidents to incidents to serious incidents to accidents is shown in Figure 1.6.

Bird's theory was that accidents occur because of:

Lack of management control or oversight

The items he felt management should control are planning, organizing, directing, controlling, and coordinating, job analysis, personal communication, selection and training, “standards” in each work activity identified measuring performance by standards and correcting performance by improving the existing program.

Origins or basic causes

The origins fall into two categories:

Personal factors include lack of knowledge or skill, improper motivation and physical or mental problems.

Job factors include inadequate work standards, design, maintenance, purchasing standards, abnormal usage, and others.

These basic causes and conditions and failure to identify them permit the second domino to fall. This initiates the possibility of further chain reaction.

Immediate causes

Immediate causes are only symptoms of the underlying problems in an organization. These underlying conditions manifest in unsafe acts and unsafe conditions.

Accident

The accident results because of the unsafe acts or conditions. There are ways to mitigate the results of unsafe acts and conditions using personal protective equipment, for example.

Injury/damage

Injury is the most important item of loss and second, comes property damage.

Figure 1.4 Heinrich's triangle.

Source: Redrawn by Ostrom (2022).

Figure 1.5 Frank Bird's theory of accident causation.

Source: Ostrom (2022).

Figure 1.6 Frank Bird's accident triangle.

Source: Redrawn by Ostrom (2022).

The Swiss cheese model of accident causation was developed by James Reason (1990, 1997). Figure 1.7 shows a depiction of the model.

In the Swiss cheese model defenses, barriers, and safeguards are integral to ensuring the safety of a system. Modern complex systems have many defensive layers. These include engineered components like alarms, physical barriers, automatic shutdowns, and interlocks. Other controls rely on the human. These are the key operating personnel in the system and include operators, pilots, medical personnel, and maintenance personnel. Procedures and other administrative control are also an important component of safety.

Figure 1.7 James Reason's Swiss cheese model.

Source: Redrawn by Ostrom (2022).

As Reason explains; “In an ideal world each defensive layer would be intact. However, they are more like slices of Swiss cheese, having many holes – though unlike in the cheese, these holes are continually opening, shutting, and shifting their location. The presence of holes in anyone “slice” does not normally cause a bad outcome. Usually, this can happen only when the holes in many layers momentarily line up to permit a trajectory of accident opportunity, bringing hazards into damaging contact with victims.”

The holes in the defenses, according to Reason, come about for two reasons: active failures and latent conditions. Adverse events involve a combination of these two sets of factors.

Active failures are the unsafe acts committed by people. Unsafe acts include slips, lapses, fumbles, mistakes, and procedural violations. These types of failures have their influence on defenses for a short period of time.

Latent conditions are those that, as the name implies, are hidden in a system until a set of conditions occur that triggers this type of failure to manifest itself. These types of conditions are, for example, faulty protection systems, untested interlocks that are faulty, or faulty design or construction. The fall of the Champlain Tower collapse in June of 2021 was probably due to unrepaired structural damage, or latent failures. They can also be personnel issues like overworked important employees, time pressure, or inadequate equipment. The COVID‐19 epidemic has caused health care workers to experience great amounts of stress that could lead to being a latent condition.

The point of this model is that there are holes in the defenses all the time and if the conditions line up an accident can happen.

The accident causation models discussed earlier are considered Simple Linear or Complex Linear (Safeopedia 2017). That is that accidents are a culmination of a series of events or circumstances. There is a sequential interaction of events. An event occurs and his leads to the next event. Heinrich's Domino Theory (1931) is the classic example. As shown earlier, the sequence is broken by removing one of the events the disaster will be avoided.

Complex Linear presumes that accidents are the result of a combination of latent hazards and unsafe acts that continue to happen in a sequential way. The model considers a variety of factors that include the environmental as well as organizational effects. The application of the model enables the set‐up of safety barriers and defenses along the timeline of the events (contributing factors). The Swiss cheese model is considered Complex Linear (Reason 1990, 1997).

Complex non‐linear accidents are the results of a combination of mutually interacting variables occurring in real world environments (Safeopedia 2017). These models seek to understand the interactions through careful analysis. A systemic model focuses on interactions and functions of the system rather than just individual events. Accidents are regarded as emergent rather than resultant phenomena.

Hollangel and Örjan (2004) and Hollangel (2012) FRAM (Functional Resonance Accident Model) is an example of a complex non‐linear accident causation model. This is a very complex model. Hollangel's idea is that in a system there are numerous interactions between components and systems. Instead of being a linear sequence of events, one activity/event can influence one or more of the other activities/events. A path can lead to success or failure depending on the variability in the activities/events. An accident can be caused by the variability in the system. The variability is a result of the variable and different conditions, group interactions, resources allocation, time available, control functions, and many more possibilities. Hollangel describes resonance of a system as a function of an activity/events' variability. This means that if its variability is unusually high then there could be consequences spreading dynamically to the other functions of the system through not necessarily identifiable couplings. FRAM enables a better understanding of a socio‐technical system, by avoiding decomposing the system into smaller components and characteristics. The process itself forces questioning rather than finding straight clear answers, as it does not include the typical cause‐effect models. The process is time consuming and requires the accident analyst to do “what‐iffing” to develop the best model of an accident. Figures 1.8 and 1.9 show the basic unit of the FRAM model and an example of a possible connection.