ABSTRACT The MTO-E method for event investigation is described in the light of almost 20 years of... more ABSTRACT The MTO-E method for event investigation is described in the light of almost 20 years of usage in the Swedish nuclear industry. Various problems are addressed in the context of the method, e.g. accident models, causality, the use of the barrier concept, the meaning of safety culture, and the process of going from problem identification to problem solving. It is argued that future applications of in-depth investigations should focus more on (innovative) methods when suggesting remedial actions as a consequence of information derived from event investigations.
ABSTRACT The aim of the present study, is to identify strengths and weaknesses of the technical s... more ABSTRACT The aim of the present study, is to identify strengths and weaknesses of the technical safety review process at a Swedish Nuclear Power Plant (NPP). In this context, the function of safety reviews are understood as expert judgements on proposals for design modifications1 and redesign of technical systems (i.e. commercial nuclear reactors), supported by formalised safety review processes. The chosen methodology is using two complementary methods: interviews of personnel performing safety reviews, and analysis of safety review reports from 2005 to 2009.The study shows that personal integrity is a trademark of the review staff and there are sufficient support systems to ensure high quality. The partition between primary and independent review is positive, having different focus and staff with different skills and perspectives making the reviews, which implies supplementary roles. The process contributes to “getting the right things done the right way”. The study also shows that though efficient communication, feedback, processes for continuous improvement, and “learning organizations” are well known success factors in academia, it is not that simple to implement and accomplish in real life.It is argued that future applications of safety review processes should focus more on communicating and clarifying the process and its adherent requirements, and improve the feedback system within the process.
ABSTRACT The context and habits of accident investigation practices were explored by means of que... more ABSTRACT The context and habits of accident investigation practices were explored by means of questionnaire data obtained from accident investigators in the healthcare, transportation, nuclear and rescue sectors in Sweden. Issues explored included; resources, training, time spent in different phases of an investigation, methods and procedures, beliefs about causes to accidents, communication issues, etc. Examples of findings were: differences in the extent to which the ‘human factor’ was perceived as a dominant cause to accidents; manning resources to support investigations were perceived as rather scarce; underutilization of data from safety related processes such as risk analysis and auditing data; the phase of suggesting remedial actions (recommendations) were comparatively brief and generally not well supported. A majority of the investigators thought that the investigations were free from pressures to follow a specific direction; the investigators also thought that performing an investigation in itself (regardless of the specific results) had positive influences on safety. A majority of the investigators thought that upper management had a relatively strong influence on safety in the organizations. The results are discussed in terms of suggestions for strategies to strengthen investigation practices – particularly those conducted as part-time work in organizations.
ABSTRACT A model of experience feedback (the CHAIN model) that emphasizes the whole chain from in... more ABSTRACT A model of experience feedback (the CHAIN model) that emphasizes the whole chain from initial reporting to preventive measures is used to identify important research needs in the field of learning from accidents. Based on the model, six quality criteria for experience feedback after an accident or incident are presented. Research on experience feedback from accidents is reviewed. The overall conclusion is that the discipline of experience feedback has not been sufficiently self-reflective. The process of experience feedback can and should be applied to experience feedback itself, but that is rarely done. Evaluation studies are needed that provide hard (evidence-based) information about the effects of various methodologies and organizational structures. Four types of studies are particularly important for the development of evidence-based accident investigation practices: (1) studies of the effects and the efficiency of different accident investigation methods, (2) studies of the dissemination of conclusions from accident investigation, (3) follow-up studies of the extent to which accident investigation reports give rise to actual preventive measures, and (4) studies of the integration of experience feedback systems into overall systems of risk management.
The concept of safety culture has become established in safety management applications in all maj... more The concept of safety culture has become established in safety management applications in all major safety-critical domains. The idea that safety culture somehow represents a "systemic view" on safety is seldom explicitly spoken out, but nevertheless seem to linger behind many safety culture discourses. However, in this paper we argue that the "new" contribution to safety management from safety culture never really became integrated with classical engineering principles and concepts. This integration would have been necessary for the development of a more genuine systems-oriented view on safety; e.g. a conception of safety in which human, technological, organisational and cultural factors are understood as mutually interacting elements. Without of this integration, researchers and the users of the various tools and methods associated with safety culture have sometimes fostered a belief that "safety culture" in fact represents such a systemic view about safety. This belief is, however, not backed up by theoretical or empirical evidence. It is true that safety culture, at least in some sense, represents a holistic term-a totality of factors that include human, organisational and technological aspects. However, the departure for such safety culture models is still human and organisational factors rather than technology (or safety) itself. The aim of this paper is to critically review the various uses of the concept of safety culture as representing a systemic view on safety. The article will take a look at the concepts of culture and safety culture based on previous studies, and outlines in more detail the theoretical challenges in safety culture as a systems concept. The paper also presents recommendations on how to make safety culture more systemic.
ABSTRACT The MTO-E method for event investigation is described in the light of almost 20 years of... more ABSTRACT The MTO-E method for event investigation is described in the light of almost 20 years of usage in the Swedish nuclear industry. Various problems are addressed in the context of the method, e.g. accident models, causality, the use of the barrier concept, the meaning of safety culture, and the process of going from problem identification to problem solving. It is argued that future applications of in-depth investigations should focus more on (innovative) methods when suggesting remedial actions as a consequence of information derived from event investigations.
ABSTRACT The aim of the present study, is to identify strengths and weaknesses of the technical s... more ABSTRACT The aim of the present study, is to identify strengths and weaknesses of the technical safety review process at a Swedish Nuclear Power Plant (NPP). In this context, the function of safety reviews are understood as expert judgements on proposals for design modifications1 and redesign of technical systems (i.e. commercial nuclear reactors), supported by formalised safety review processes. The chosen methodology is using two complementary methods: interviews of personnel performing safety reviews, and analysis of safety review reports from 2005 to 2009.The study shows that personal integrity is a trademark of the review staff and there are sufficient support systems to ensure high quality. The partition between primary and independent review is positive, having different focus and staff with different skills and perspectives making the reviews, which implies supplementary roles. The process contributes to “getting the right things done the right way”. The study also shows that though efficient communication, feedback, processes for continuous improvement, and “learning organizations” are well known success factors in academia, it is not that simple to implement and accomplish in real life.It is argued that future applications of safety review processes should focus more on communicating and clarifying the process and its adherent requirements, and improve the feedback system within the process.
ABSTRACT The context and habits of accident investigation practices were explored by means of que... more ABSTRACT The context and habits of accident investigation practices were explored by means of questionnaire data obtained from accident investigators in the healthcare, transportation, nuclear and rescue sectors in Sweden. Issues explored included; resources, training, time spent in different phases of an investigation, methods and procedures, beliefs about causes to accidents, communication issues, etc. Examples of findings were: differences in the extent to which the ‘human factor’ was perceived as a dominant cause to accidents; manning resources to support investigations were perceived as rather scarce; underutilization of data from safety related processes such as risk analysis and auditing data; the phase of suggesting remedial actions (recommendations) were comparatively brief and generally not well supported. A majority of the investigators thought that the investigations were free from pressures to follow a specific direction; the investigators also thought that performing an investigation in itself (regardless of the specific results) had positive influences on safety. A majority of the investigators thought that upper management had a relatively strong influence on safety in the organizations. The results are discussed in terms of suggestions for strategies to strengthen investigation practices – particularly those conducted as part-time work in organizations.
ABSTRACT A model of experience feedback (the CHAIN model) that emphasizes the whole chain from in... more ABSTRACT A model of experience feedback (the CHAIN model) that emphasizes the whole chain from initial reporting to preventive measures is used to identify important research needs in the field of learning from accidents. Based on the model, six quality criteria for experience feedback after an accident or incident are presented. Research on experience feedback from accidents is reviewed. The overall conclusion is that the discipline of experience feedback has not been sufficiently self-reflective. The process of experience feedback can and should be applied to experience feedback itself, but that is rarely done. Evaluation studies are needed that provide hard (evidence-based) information about the effects of various methodologies and organizational structures. Four types of studies are particularly important for the development of evidence-based accident investigation practices: (1) studies of the effects and the efficiency of different accident investigation methods, (2) studies of the dissemination of conclusions from accident investigation, (3) follow-up studies of the extent to which accident investigation reports give rise to actual preventive measures, and (4) studies of the integration of experience feedback systems into overall systems of risk management.
The concept of safety culture has become established in safety management applications in all maj... more The concept of safety culture has become established in safety management applications in all major safety-critical domains. The idea that safety culture somehow represents a "systemic view" on safety is seldom explicitly spoken out, but nevertheless seem to linger behind many safety culture discourses. However, in this paper we argue that the "new" contribution to safety management from safety culture never really became integrated with classical engineering principles and concepts. This integration would have been necessary for the development of a more genuine systems-oriented view on safety; e.g. a conception of safety in which human, technological, organisational and cultural factors are understood as mutually interacting elements. Without of this integration, researchers and the users of the various tools and methods associated with safety culture have sometimes fostered a belief that "safety culture" in fact represents such a systemic view about safety. This belief is, however, not backed up by theoretical or empirical evidence. It is true that safety culture, at least in some sense, represents a holistic term-a totality of factors that include human, organisational and technological aspects. However, the departure for such safety culture models is still human and organisational factors rather than technology (or safety) itself. The aim of this paper is to critically review the various uses of the concept of safety culture as representing a systemic view on safety. The article will take a look at the concepts of culture and safety culture based on previous studies, and outlines in more detail the theoretical challenges in safety culture as a systems concept. The paper also presents recommendations on how to make safety culture more systemic.
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Papers by Carl Rollenhagen