This paper explores the various options for organisational structures by examining some high-prof... more This paper explores the various options for organisational structures by examining some high-profile incidents in the light of a number of theories that have been put forward to explain behaviours. On first inspection, it might be concluded that a common theme emerging from studying the results of such organisational behaviours might be the slavish conformance to “acceptable” or expected “institutionalised” structures which stipulate impenetrable layers of middle management between the “sharp end” teams and the responsible executives and their governing Boards. This so called “clay layer” has been highlighted as a major factor in high profile incidents such as Challenger, Columbia, Chernobyl, Longford, Macondo blow out and many others . However, on closer examination, there are other examples of corporate failures, (such as the Post Office computerisation scandal) which suggest that the “clay layer” in fact serves another purpose; to allow credible “deniability” for the controlling ...
Taalproblemen veroorzaken onveiligheid op het werk. Deze studie inventariseert welk wetenschappel... more Taalproblemen veroorzaken onveiligheid op het werk. Deze studie inventariseert welk wetenschappelijk onderzoek in een aantal economische sectoren is gedaan. Deze studie laat zien dat wetenschappelijk onderzoek naar 'taal en veiligheid' nog pril is en meer aandacht op de wetenschappelijke onderzoeksagenda verdient.
In the course of the investigation into an explosion in a fireworks storage facility in the Nethe... more In the course of the investigation into an explosion in a fireworks storage facility in the Netherlands risk analyses were performed on the facility as it should have been under the current legislation and permits and as it actually was. The results show that under the current legislation the facility was acceptable in its present location, if it adhered to the terms of its permit. However as it actually was it was completely unacceptable. The results are compared with the results of analyses of industrial facilities and other hazardous activities to place the risk of storage of pyrotechnics in the context of other industrial risk.
The assumption that risk, represented as an expected value of the loss could be implied to be a m... more The assumption that risk, represented as an expected value of the loss could be implied to be a measure of safety, in a cost benefit analysis, is firmly entrenched in economic risk analysis. However, this does not mean that without a marker, the value of a loss, can be established with any necessary level of certainty to make such a cost balancing act ethically possible. The appropriateness of using the Value of a Statistical Life (VOSL) at all in a safety analysis, is a matter of perspective, which renders attempts to establish a uniform value of a statistical life questionable. This makes it questionable whether decisions from which values for a VOSL were evaluated, really were based on consideration of saving lives, or whether other arguments, such as available budget, were much more dominant. Ethical considerations do not seem to be in the frame of corporate risk management, where lossof-life catastrophes appear to be simply the cost of doing business. Because there is no real basis for any estimate of the value of a statistical life, the values employed in cost-benefit analyses therefore only seem to serve the purpose of dissembling, concealing that the decision is taken on grounds other than saving human lives, or even that potential harm to humans was not even considered. The strict meaning given to resilience as at most to make a plan for recovery and see if we can live with the consequences, seems just another step towards putting the economy before people.
Big Data can help overcome various problems that exist in present risk analysis practices. By ana... more Big Data can help overcome various problems that exist in present risk analysis practices. By analysing systems as a whole, it is no longer necessary to define in advance what a failure is and what a success is. It is also possible to evaluate how factors that are considered to promote success can combine into catastrophic failures. Big in Big Data is relative. What was called big data 25 years ago is now called small. The continuous development of analysis techniques over the years have resulted in several operational models that use the concept of Big Data. They will become better as the technology and the accessibility of data further improves. With this new generation of systems models, accidents and incidents do not have to wait for analysis to after the fact. They can be studied beforehand in a model. Replacing hindsight by foresight can help to make the world safer, if we desire to do so.
Publication costs assisted by the Laboratory for Electrochemistry Anion exchange of chloride and ... more Publication costs assisted by the Laboratory for Electrochemistry Anion exchange of chloride and nitrate ions has been observed between a Na(N03,Cl) melt and a sodium zeolite A with occluded NaN03: Na22(AlSi0&2(NO&o a t 375 and 450". The replacement exchange can be described by an ideal exchange isotherm with a maximum exchange capacity of 1.81 and 1.67 C1-ion per zeolite unit a t 375 and 450", respectively. The standard free enthalpy of exchange was found to be .~Go.T, =-7.7 kcal/mol a t 375".
ABSTRACT The concept of reducing risk As Low As Reasonably Practicable (ALARP) as presented by th... more ABSTRACT The concept of reducing risk As Low As Reasonably Practicable (ALARP) as presented by the UK Health and Safety Executive for the purpose of discharging its decision-taking responsibilities and the principle of balancing cost and benefits through monetary Cost Benefit Analysis (CBA) which is used more widely in health and safety decision-making seem to occupy the extremes of the decision making spectrum. ALARP seems on the qualitative, holistic, principles based side whereas CBA seems on the quantitative, limited, precisely defined side. These characteristics expose both principles to criticism. Application of the ALARP concept may to lead to different decisions in similar contexts resulting in uncertainty and unpredictability in decision making. CBA leads to decisions in which only money counts and all that cannot be expressed in money or is perceived of no monetary value is neglected. In this paper this issue is explored in more depth, and it is concluded that they are part of the general decision making process. The nature of the relevant safety laws and how they are applied frame the application of these concepts. If the level of acceptable risk is not explicitly set by law, the risk level resulting from compliance to the regulations is just as accidental as the Value of a Statistical Life (VOSL) found from ex post evaluations of decisions. ALARP, QRA and CBA are part of the grander scheme of making decisions. Throughout, the focus is on the principle rather than the practices of ALARP and CBA in reducing risk.
Safety and Reliability: Methodology and Applications, 2014
ABSTRACT The first version of Platypus was made in May 2013. Though the initial program could alr... more ABSTRACT The first version of Platypus was made in May 2013. Though the initial program could already be used to calculate an entire site it was not very user friendly. Since then, there was a strong drive to improve the functionality of the program, especially with respect to the improvement of analysis tools. Improvements included: an engine to read equipment lists, an engine to change parameters in subsets of process equipment in a plant and copying subsets of the plants. This combination of features has led to a piece of software that enables left-hand side BBN-based risk analyses of entire chemical—or process plants, something that was never done before. Note that detailed scientific information is not disseminated in this paper. Rigorous scientific reporting will take place after full testing of the program. Nevertheless, the reader may increase their understanding by reading earlier publications about this project that explain the philosophy and theoretical framework of Platypus. 1.3 This paper This paper is limited to a description of the capabilities of Platypus. It shows the results of case study that was performed with Platypus version 0.7.10. The case study involves test calculations for the reactive section in an ethylene oxidation process that contains 4 reactors. Since the program is still under development, these results are preliminary. That means that the results in this paper are used to demonstrate how the results that Platypus yields and how they can be used for risk-analyses of process plants. The results should not be interpreted as exact. A brief description of the structure and some of the software features of Platypus is enclosed in this paper.
… safety assessment and management, PSAM 4: …, 1998
... In the PASO document two joint aims were defined for the future development of Schiphol airpo... more ... In the PASO document two joint aims were defined for the future development of Schiphol airport: It should develop into a mainport and the Amsterdam I Zwanenburg veldertbaan Buitenveldert NEW I buiten zwanenburglaan-I* J\ Aalsmeerbaan V Kaagbaq ... for new and 10" Vyr. ...
The development of the Netherlands international airport Schiphol has been the subject of fierce ... more The development of the Netherlands international airport Schiphol has been the subject of fierce political debate for several decades. One of the considerations has been the safety of the population living around the airport, the density of which has been and still is growing. The concern about this third party risk has been enhanced by the crash in 1993 of
As part of an ongoing effort by the ministry of Social Affairs and Employment of The Netherlands ... more As part of an ongoing effort by the ministry of Social Affairs and Employment of The Netherlands a research project is being undertaken to construct a causal model for the most commonly occurring scenarios related to occupational risk. This model should provide quantitative insight in the causes and consequences of occupational accidents. The results should be used to help selecting optimal strategies to reduce these risks taking the costs of accidents and of measures into account. The research is undertaken by an international consortium under the name of Workgroup Occupational Risk Model. One of the components of the model is a tool to systematically classify and analyse past accidents. This tool: ''Storybuilder'' and its place in the Occupational Risk Model (ORM) are described in the paper. The paper gives some illustrations of the application of the Storybuilder, drawn from the study of ladder accidents, which forms one of the biggest single accident categories in the Dutch data.
A fimdamental analysis of crime and the juridical systems to punish crime has yielded a starting ... more A fimdamental analysis of crime and the juridical systems to punish crime has yielded a starting point for quantitative risk analysis of security risks. This method is called the MMO concept as a generic concept for the design of security barriers and their evaluation by quantitative risk analysis methods. It is based on a simplification of the basic elements for proving criminal liability that a defendant committed a crime under US law: motive, means and opportunity. These three elements form the preconditions that are needed to let an ill meaning person to develop into a hazard or threat. The MMO concept also forms the key to the development of successful barriers against the completion of the actual act. Taking one of these three away would render the hazard meffective. This enables the development of a model for security threats along the same lines as safety threats and opens the possibility for similar qualitative and quantitative analysis. The MMO concept may seem relatively ...
This paper explores the various options for organisational structures by examining some high-prof... more This paper explores the various options for organisational structures by examining some high-profile incidents in the light of a number of theories that have been put forward to explain behaviours. On first inspection, it might be concluded that a common theme emerging from studying the results of such organisational behaviours might be the slavish conformance to “acceptable” or expected “institutionalised” structures which stipulate impenetrable layers of middle management between the “sharp end” teams and the responsible executives and their governing Boards. This so called “clay layer” has been highlighted as a major factor in high profile incidents such as Challenger, Columbia, Chernobyl, Longford, Macondo blow out and many others . However, on closer examination, there are other examples of corporate failures, (such as the Post Office computerisation scandal) which suggest that the “clay layer” in fact serves another purpose; to allow credible “deniability” for the controlling ...
Taalproblemen veroorzaken onveiligheid op het werk. Deze studie inventariseert welk wetenschappel... more Taalproblemen veroorzaken onveiligheid op het werk. Deze studie inventariseert welk wetenschappelijk onderzoek in een aantal economische sectoren is gedaan. Deze studie laat zien dat wetenschappelijk onderzoek naar 'taal en veiligheid' nog pril is en meer aandacht op de wetenschappelijke onderzoeksagenda verdient.
In the course of the investigation into an explosion in a fireworks storage facility in the Nethe... more In the course of the investigation into an explosion in a fireworks storage facility in the Netherlands risk analyses were performed on the facility as it should have been under the current legislation and permits and as it actually was. The results show that under the current legislation the facility was acceptable in its present location, if it adhered to the terms of its permit. However as it actually was it was completely unacceptable. The results are compared with the results of analyses of industrial facilities and other hazardous activities to place the risk of storage of pyrotechnics in the context of other industrial risk.
The assumption that risk, represented as an expected value of the loss could be implied to be a m... more The assumption that risk, represented as an expected value of the loss could be implied to be a measure of safety, in a cost benefit analysis, is firmly entrenched in economic risk analysis. However, this does not mean that without a marker, the value of a loss, can be established with any necessary level of certainty to make such a cost balancing act ethically possible. The appropriateness of using the Value of a Statistical Life (VOSL) at all in a safety analysis, is a matter of perspective, which renders attempts to establish a uniform value of a statistical life questionable. This makes it questionable whether decisions from which values for a VOSL were evaluated, really were based on consideration of saving lives, or whether other arguments, such as available budget, were much more dominant. Ethical considerations do not seem to be in the frame of corporate risk management, where lossof-life catastrophes appear to be simply the cost of doing business. Because there is no real basis for any estimate of the value of a statistical life, the values employed in cost-benefit analyses therefore only seem to serve the purpose of dissembling, concealing that the decision is taken on grounds other than saving human lives, or even that potential harm to humans was not even considered. The strict meaning given to resilience as at most to make a plan for recovery and see if we can live with the consequences, seems just another step towards putting the economy before people.
Big Data can help overcome various problems that exist in present risk analysis practices. By ana... more Big Data can help overcome various problems that exist in present risk analysis practices. By analysing systems as a whole, it is no longer necessary to define in advance what a failure is and what a success is. It is also possible to evaluate how factors that are considered to promote success can combine into catastrophic failures. Big in Big Data is relative. What was called big data 25 years ago is now called small. The continuous development of analysis techniques over the years have resulted in several operational models that use the concept of Big Data. They will become better as the technology and the accessibility of data further improves. With this new generation of systems models, accidents and incidents do not have to wait for analysis to after the fact. They can be studied beforehand in a model. Replacing hindsight by foresight can help to make the world safer, if we desire to do so.
Publication costs assisted by the Laboratory for Electrochemistry Anion exchange of chloride and ... more Publication costs assisted by the Laboratory for Electrochemistry Anion exchange of chloride and nitrate ions has been observed between a Na(N03,Cl) melt and a sodium zeolite A with occluded NaN03: Na22(AlSi0&2(NO&o a t 375 and 450". The replacement exchange can be described by an ideal exchange isotherm with a maximum exchange capacity of 1.81 and 1.67 C1-ion per zeolite unit a t 375 and 450", respectively. The standard free enthalpy of exchange was found to be .~Go.T, =-7.7 kcal/mol a t 375".
ABSTRACT The concept of reducing risk As Low As Reasonably Practicable (ALARP) as presented by th... more ABSTRACT The concept of reducing risk As Low As Reasonably Practicable (ALARP) as presented by the UK Health and Safety Executive for the purpose of discharging its decision-taking responsibilities and the principle of balancing cost and benefits through monetary Cost Benefit Analysis (CBA) which is used more widely in health and safety decision-making seem to occupy the extremes of the decision making spectrum. ALARP seems on the qualitative, holistic, principles based side whereas CBA seems on the quantitative, limited, precisely defined side. These characteristics expose both principles to criticism. Application of the ALARP concept may to lead to different decisions in similar contexts resulting in uncertainty and unpredictability in decision making. CBA leads to decisions in which only money counts and all that cannot be expressed in money or is perceived of no monetary value is neglected. In this paper this issue is explored in more depth, and it is concluded that they are part of the general decision making process. The nature of the relevant safety laws and how they are applied frame the application of these concepts. If the level of acceptable risk is not explicitly set by law, the risk level resulting from compliance to the regulations is just as accidental as the Value of a Statistical Life (VOSL) found from ex post evaluations of decisions. ALARP, QRA and CBA are part of the grander scheme of making decisions. Throughout, the focus is on the principle rather than the practices of ALARP and CBA in reducing risk.
Safety and Reliability: Methodology and Applications, 2014
ABSTRACT The first version of Platypus was made in May 2013. Though the initial program could alr... more ABSTRACT The first version of Platypus was made in May 2013. Though the initial program could already be used to calculate an entire site it was not very user friendly. Since then, there was a strong drive to improve the functionality of the program, especially with respect to the improvement of analysis tools. Improvements included: an engine to read equipment lists, an engine to change parameters in subsets of process equipment in a plant and copying subsets of the plants. This combination of features has led to a piece of software that enables left-hand side BBN-based risk analyses of entire chemical—or process plants, something that was never done before. Note that detailed scientific information is not disseminated in this paper. Rigorous scientific reporting will take place after full testing of the program. Nevertheless, the reader may increase their understanding by reading earlier publications about this project that explain the philosophy and theoretical framework of Platypus. 1.3 This paper This paper is limited to a description of the capabilities of Platypus. It shows the results of case study that was performed with Platypus version 0.7.10. The case study involves test calculations for the reactive section in an ethylene oxidation process that contains 4 reactors. Since the program is still under development, these results are preliminary. That means that the results in this paper are used to demonstrate how the results that Platypus yields and how they can be used for risk-analyses of process plants. The results should not be interpreted as exact. A brief description of the structure and some of the software features of Platypus is enclosed in this paper.
… safety assessment and management, PSAM 4: …, 1998
... In the PASO document two joint aims were defined for the future development of Schiphol airpo... more ... In the PASO document two joint aims were defined for the future development of Schiphol airport: It should develop into a mainport and the Amsterdam I Zwanenburg veldertbaan Buitenveldert NEW I buiten zwanenburglaan-I* J\ Aalsmeerbaan V Kaagbaq ... for new and 10" Vyr. ...
The development of the Netherlands international airport Schiphol has been the subject of fierce ... more The development of the Netherlands international airport Schiphol has been the subject of fierce political debate for several decades. One of the considerations has been the safety of the population living around the airport, the density of which has been and still is growing. The concern about this third party risk has been enhanced by the crash in 1993 of
As part of an ongoing effort by the ministry of Social Affairs and Employment of The Netherlands ... more As part of an ongoing effort by the ministry of Social Affairs and Employment of The Netherlands a research project is being undertaken to construct a causal model for the most commonly occurring scenarios related to occupational risk. This model should provide quantitative insight in the causes and consequences of occupational accidents. The results should be used to help selecting optimal strategies to reduce these risks taking the costs of accidents and of measures into account. The research is undertaken by an international consortium under the name of Workgroup Occupational Risk Model. One of the components of the model is a tool to systematically classify and analyse past accidents. This tool: ''Storybuilder'' and its place in the Occupational Risk Model (ORM) are described in the paper. The paper gives some illustrations of the application of the Storybuilder, drawn from the study of ladder accidents, which forms one of the biggest single accident categories in the Dutch data.
A fimdamental analysis of crime and the juridical systems to punish crime has yielded a starting ... more A fimdamental analysis of crime and the juridical systems to punish crime has yielded a starting point for quantitative risk analysis of security risks. This method is called the MMO concept as a generic concept for the design of security barriers and their evaluation by quantitative risk analysis methods. It is based on a simplification of the basic elements for proving criminal liability that a defendant committed a crime under US law: motive, means and opportunity. These three elements form the preconditions that are needed to let an ill meaning person to develop into a hazard or threat. The MMO concept also forms the key to the development of successful barriers against the completion of the actual act. Taking one of these three away would render the hazard meffective. This enables the development of a model for security threats along the same lines as safety threats and opens the possibility for similar qualitative and quantitative analysis. The MMO concept may seem relatively ...
Samenvatting Taalproblemen veroorzaken onveiligheid op het werk. Deze studie inventariseert welk ... more Samenvatting Taalproblemen veroorzaken onveiligheid op het werk. Deze studie inventariseert welk wetenschappelijk onderzoek in een aantal economische sectoren is gedaan en welk stadium van risico beheersing zij behandelen. Niet in alle sectoren is onderzoek gedaan naar taalproblemen als ongeval oorzaak. Het risico door taalproblemen is daarmee deels onbekend en dus onbeheerst. Inzicht ontbreekt in zowel de aard van dit type gevaar als in de omvang van het effect in de zorg-, agro-, transport-en de bouwsector. De zorg sector is een bijzonder geval omdat daar door aanwezigheid en interactie van en met patiënten slachtoffers van ongevallen door taalproblemen te verwachten zijn. In de transport en diensten sector speelt een vergelijkbaar registratieprobleem met slachtoffers onder het publiek. In de transport-en agro sectoren zijn maatregelen genomen zonder analyse van het risico. Deze studie laat zien dat wetenschappelijk onderzoek naar 'taal en veiligheid' nog pril is en meer aandacht op de wetenschappelijke onderzoeksagenda verdient. Abstract Language issues cause safety problems at work. This study presents an inventory of scientific studies in the economic sectors and assesses which level of risk management they address. Complications with language have not been investigated comprehensively across sectors as a causal factor in accidents. This leaves language related risks partially unknown, hence uncontrolled. There is lack of insight in both the nature and magnitude of this danger in healthcare, agricultural, transport and construction sectors. Healthcare is especially troublesome since patients might be victims of language related accidents due to their presence and interaction. The same may occur to members of the public in traffic accidents. In transport and agricultural sectors safety measures were taken without any analysis of language related risks. This study shows that scientific research on 'language and safety' is in its infancy and requires priority on the research agenda.
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