In this article, the authors apply the intervention mapping (IM) protocol to develop safety leadership training for a rail infrastructure maintenance company. The IM protocol helps to create an ...evidence-based intervention in a structured way, based on concrete evidence. The application of IM within the occupational safety domain is limited, a research gap that this article bridges with the development and testing of a safety leadership intervention to promote safety behavior among managers. The company was positively and actively engaged in the training program thanks to the IM protocol. The local support group took full advantage of the opportunities to provide input during the development of the training’s various components. Despite this, interpersonal problems within the leadership team itself, such as a lack of psychological safety, were not identified during the needs assessment. These issues had an impact on the overall effectiveness of the training, as they manifested during the training when managers met physically for the first time in several years (due to the coronavirus). Our IM protocol will be adjusted accordingly for future applications, and we hope that sharing our experiences will enable fellow researchers to avoid this problem.
Employee behavior plays an important role in the occurrence and prevention of incidents, affecting safety margins. In this study, we examine the potential impact of incidental learning on human ...behavior in the presence of variation in task design. Incidental learning is the day-to-day on-the-job learning that occurs unintentionally. This learning influences which behavior (schema) is more likely to be activated in the employee’s brain. We posit that an incorrect schema can be activated and lead to undesired behavior if the employee is often exposed to (visually) similar tasks that require different behavior. In rail transport, there is a risk of trains passing through red signals. The train driver’s behavior plays an important role in preventing these signal passed at danger (SPAD) incidents. In this study we used speed and location data to analyze train driver deceleration behavior during red signal approaches in the Netherlands. The Dutch rail system showed variation in yellow signal aspects and signal distance. An analysis using 19 months of empirical data indicated changes in behavior when the employee had been previously exposed to different behavior requirements in the same location with a similar yellow signal. These results imply that task design can be improved by taking into consideration what an employee is exposed to during other moments of the shift, and not just during the execution of the specific task.
ObjectivesThe goal of sentinel event (SE) analysis is to prevent recurrence. However, the rate of SEs has remained constant over the past years. Research suggests this is in part due to the quality ...of recommendations. Currently, standards for the selection of recommendations are lacking. Developing a method to grade recommendations could help in both designing and selecting interventions most likely to improve patient safety. The aim of this study was to (1) develop a user-friendly method to grade recommendations and (2) assess its applicability in a large series of Dutch perioperative SE analysis reports.MethodsBased on two grading methods, we developed the recommendation improvement matrix (RIM). Applicability was assessed by analysing all Dutch perioperative SE reports over a 12-month period. After which interobserver agreement was studied.ResultsIn the RIM, two elements are crucial: whether the recommendation intervenes before or after an SE and whether it eliminates or controls the hazard. Applicability was evaluated in 115 analysis reports, encompassing 161 recommendations. Recommendation quality varied from the highest, category A, to the lowest, category D, with category A accounting for 44%, category B for 35%, category C for 2% and category D for 19% of recommendations. There was a fair interobserver agreement.ConclusionThe RIM can be used to grade recommendations in SE analysis and could possibly help in both designing and selecting interventions. It is relatively simple, user-friendly and has the potential to improve patient safety. The RIM can help formulate effective and sustainable recommendations, a second key objective of the RIM is to foster and facilitate constructive dialogue among those responsible for patient safety.
The field of safety and incident prevention is becoming more and more data based. Data can help support decision making for a more productive and safer work environment, but only if the data can be, ...is and should be trusted. Especially with the advance of more data collection of varying quality, checking and judging the data is an increasingly complex task. Within such tasks, cognitive biases are likely to occur, causing analysists to overestimate the quality of the data and safety experts to base their decisions on data of insufficient quality. Cognitive biases describe generic error tendencies of persons, that arise because people tend to automatically rely on their fast information processing and decision making, rather than their slow, more effortful system. This article describes five biases that were identified in the verification of a safety indicator related to train driving. Suggestions are also given on how to formalize the verification process. If decision makers want correct conclusions, safety experts need good quality data. To make sure insufficient quality data is not used for decision making, a solid verification process needs to be put in place that matches the strengths and limits of human cognition.
BackgroundThe recurrence of sentinel events (SEs) is a persistent problem worldwide, despite repeated analyses and recommendations formulated to prevent recurrence. Research suggests this is partly ...attributable to the quality of the recommendations, and determining if a recommendation will be effective is not yet covered by an adequate guideline. Our objectives were to (1) develop and validate criteria for high-quality recommendations, and (2) evaluate recommendations using the criteria developed.Methods(1) Criteria were developed by experts using the bowtie method. Medical doctors then determined if the recommendations of Dutch in-hospital SE analysis reports met the criteria, after which interobserver variability was tested. (2) Researchers determined which recommendations of Dutch perioperative SE analysis reports produced from 2017 to 2018 met the criteria.ResultsThe criteria were: (1) a recommendation needs to be well defined and clear, (2) it needs to specifically describe the intended changes, and (3) it needs to describe how it will reduce the risk or limit the consequences of a similar SE. Validation of criteria showed substantial interobserver agreement. The SE analysis reports (n=115) contained 442 recommendations, of which 64% failed to meet all criteria, and 28% of reports did not contain a single recommendation that met the criteria.ConclusionWe developed and validated criteria for high-quality recommendations. The majority of recommendations did not meet our criteria. It was disconcerting to find that over a quarter of the investigations did not produce a single recommendation that met the criteria, not even in SEs with a fatal outcome. Healthcare providers have an obligation to prevent SEs, and certainly their recurrence. We anticipate that using these criteria to determine the potential of recommendations will aid in this endeavour.
The future of safety science Swuste, Paul; Groeneweg, Jop; van Gulijk, Coen ...
Safety science,
20/May , Volume:
125
Journal Article
Peer reviewed
Open access
•Safety has improved spectacularly the last decades, and will continue to do so.•Scientific safety insights seem hardly a source of practical knowledge.•The inability to foresee safety related ...conflicts creates limits for design options.•A method is developed to assess time-dependant advancements of accident scenarios.•As a thought experiment, skip all safety laws, focus on accident processes.
Ever since safety started to be investigated in a consistent manner, around 150 years ago, there has been a tremendous improvement, both in our understanding of accident processes, and in reduction of harm and damage caused by these occupational and major accidents. Major improvements in safety theories, models and metaphors were made after World War II, with the late 1970s till the late 1990s as the ‘golden years’. But still these major accidents occur and they will keep prompting future scientific developments in safety, as they have done in the past. Reducing the frequency of major accidents remains challenging. Improving design and automation, as starting point for safety has its limits due to the complexity of processes and the inability to foresee all safety related conflicts. The modern emphasis to assure the capacity to handle unforeseen events, such as resilience promises to deliver, will become even more important in the future. Inherent safe design on the other hand make a sensible approach when designing production processes for emerging and future technologies, like nano- and biotechnology. Also, it will remain difficult for small and medium sized enterprises to adhere to complicated laws and regulations. In addition, an increased participation of stakeholder groups makes future safety decision-making even more challenging than it already is today. Yet we foresee that there may be grounds for change in which safety rules, laws and regulations are set aside, the bureaucratic approach towards safety is stopped and the focus is on dynamic accident processes detection. Today, methods are developed to automatically assess time-dependant advancement of accident scenarios and barrier degradation. This direction will contribute substantially to a future higher level of safety in different industrial sectors and might alleviate the emphasis on bureaucracy. We end with developments in two countries where safety and safety science is emerging.
Safety professionals in the Netherlands Swuste, Paul; Zwaard, Walter; Groeneweg, Jop ...
Safety science,
April 2019, 2019-04-00, 20190401, Volume:
114
Journal Article
Peer reviewed
Open access
•Dutch safety professionals have gone through major transformations.•From company safety inspectors in the 1920s, safety technicians in the 1950s.•In the 1970s safety officers are dealing with ...employee behaviour, and organisational aspects.•In the late 1990s safety services are privatized, and safety officers become to safety consultants.•There is a major gap between academic and professional developments in safety.
The origin of occupational safety, as an area of main interest of the government, the industry, the unions, and scientists starts in the Netherlands at the end of the 19th century. Roughly in the same period occupational medicine becomes a separate domain. Only just after World War II are safety professionals organised in associations. Starting as a ‘Club/werkgroep van veiligheidsinspecteurs’ (Club/Working group of Company Safety Inspectors) in 1947, it changes in 1962 into the ‘Nederlandse Vereniging van Veiligheidstechnici, NVVT’ (Dutch Association of Safety Technicians). In 1978 there is another change into a professional association, and the ‘Nederlandse Vereniging van Veiligheidskundigen, NVVK’ (Dutch Association of Safety Professionals) is formed. In 1986 this association is transformed into a knowledge association, the ‘Nederlandse Vereniging voor Veiligheidskunde, NVVK’ (Dutch Association of Safety Science). Nowadays the NVVK is still a knowledge platform for and by safety experts in the Netherlands. The association is a network of 3000 safety experts in various disciplines and departments, and by far the biggest network of experts on working conditions in the Netherlands. The NVVK is actively involved in changes in legislation and regulations, and also represents the interests of members and safety experts in general. During these 71 years of organised safety professions, major changes in position and content have occurred.
•The effectiveness of safety interventions is often unclear in practice.•Safety practitioners were surveyed on the intervention types that they use.•The use and perceived effectiveness of these ...intervention types is shown.
In the Netherlands, approximately 2.300 workers have a serious reportable accident at work every year, of which around 60 are fatal (Inspectie SZW, 2020; Bellamy et al., 2014). Safety practitioners employ many methods to improve occupational safety for workers within their companies. Interventions might, for example, be aimed at improving companies’ overall ‘safety culture’, at the introduction of a safety management system (e.g. Robson et al., 2007), or at improving the compliance of workers to specific safety rules (e.g. Peuscher and Groeneweg 2012; Bryden et al., 2016). However, the effectiveness of many of those interventions remains largely unclear (Dyreborg et al, 2015). The Dutch National Institute for Public Health and the Environment (RIVM) has started a project with the ultimate goal of developing a database filled with effective safety interventions. Developers can submit their interventions using a fixed protocol. To support this project, we developed a survey, which was sent to all members of the Dutch Society for Safety Science (NVVK). In the survey, we used a list of 48 predefined descriptions of common interventions. Respondents could indicate whether they made use of these common interventions and the extent to which they considered these effective. The survey thus provided an extensive overview of the use and perceived effectiveness of 48 specific safety interventions. In the future, these insights can support the development and testing of more effective safety interventions.
Research question: What is the influence of general management trends and research into causes of accidents on safety management? Method: The literature study is limited to English and Dutch books, ...documents and articles in the scientific, professional, and technical literature from the period 1988–2010. Results and conclusions: Quite some developments occurred in the occupational safety domain. During the period concerned three models are developed, the Dutch Tripod Model, the Swedish Occupational Risk Unit Model (QARU), and the Dutch Occupational Risk Model (QRM), a barrier based model founded on the bowtie metaphor. These models address occupational accidents from different perspectives, and surprisingly similar factors. While terminology differs, these factors are called basic risk factors, situational, or management factors. Self-regulation of companies has been a strong stimulus for research on safety management systems and audits. Traditionally research in management related topics has not been part of safety research, and thus it has to be developed. While the quality of this type of research is rather low, a general structure of safety management systems is related to the Rhineland management concept. Such evidence is found in new management models such as the EFQM/INK and, to a lesser extent, Corporate Social Responsibility (CSR). While organisational learning, its quality and effectiveness on occupational safety is not researched in this period, research interests are focussing on other organisational aspects like safety culture and climate, including a renewed interest in human behaviour.
•No relation existed between management approaches, safety theories, and safety performance.•Human errors explaining occupational accidents are still popular in the professional press.•Process safety ...outplaced the developments in occupational safety, which was leading before.•In process safety, human errors were the result of suboptimal interactions during disturbances.•Theories and models were unable to predict probabilities, and scenarios of future disasters.
Which general management and safety models and theories trends influenced safety management in the period between Three Mile Island in 1979 and Piper Alpha in 1988? In which context did these developments took place and how did this influence Dutch safety domain?
The literature study was limited to original English and Dutch documents and articles in scientific and professional literature during the period studied.
Models and theories of human errors, explaining occupational accidents were still popular in the professional literature. A system approach was introduced into mainstream safety science, starting in process safety, and subsequently moving into occupational safety. Accidents were thought to be the result of disturbances in a dynamic system, a socio-technical system, rather than just human error. Human errors were also perceived differently: they were no longer faults of people, but consequences of suboptimal interactions during process disturbances. In this period quality of safety research increased substantially, also in the Netherlands.
Major disasters in the 1980s generated knowledge on process safety, and soon process safety outplaced developments in occupational safety, which had been leading before. Theories and models in this period had advanced sufficiently to explain disasters, but were still unable to predict probabilities and scenarios of future disasters. In the 1980s ‘latent errors’ appeared in safety literature, and in The Netherlands the concept of ‘impossible accidents' appeared. Safety management was strongly influenced by developments in quality management.
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