Principles of Safety Engineering

First Unit: Accidents, understanding safety, Hazard triangle, Accident causation models,
& Swiss cheese model
Instructed by:
Harshad Shrigondekar
Assistant Professor
Centre of Excellence in
Safety Engineering & Analytics (COE-SEA),
IIT Kharagpur
[email protected]
An Insight

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 An Insight

INDUSTRY 4.0
Complexity

INDUSTRY 3.0
Today’s generation is
living the most
INDUSTRY 2.0 comfortable and
luxurious life but …….
INDUSTRY 1.0
Internet of
Things (IoT) &
Services,
Nano technology, Cyber
Electricity Biotechnology, Physical
Chemistry, New materials, Systems
Steam Engine, Combustion Recycling, etc
Weaving Loom, & Engine, & Line
Steel Treatment production
1800s 1900s 1960s Today Time

Comforts
Hazards
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 • Reason, J.
(2016). Organizatio
nal accidents
revisited. CRC
press.
• Biswas, S. K.,
Mathur, U., &
Hazra, S. K. (2021).
Fundamentals of
process safety
engineering. CRC
Press.
Piper Alpha on fire after explosion (1988) Union Carbide India Limited (UCIL) pesticide plant in Bhopal (1986)
• Killing 165 men • World's worst industrial disaster
• Costliest man-made catastrophes • Leakage & exposure of highly toxic gas methyl isocyanate (MIC)
• Total insured loss £1.7 billion (>£5 billion in 2023) • Around 2000 people were killed immediately, total >5000

Chernobyl Accident (1986) IOCL – Jaipur (2009)

• Decontamination – 500000 personnel - > 68 billion $ • Unconfined vapor cloud explosion (detonation) 4
 Energy exchange

Safety & Sustainability Model

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 Let us understand safety
• Safety+
• ISO 45001 States Safety is Freedom from Unacceptable Risk
• What does this definition provide?
✓ There is inherent risk
✓ Risk needs to be defined
✓ Risk needs to be measured
✓ Safety is a verb that can be adapted
• Accidents: unplanned events - An unplanned event or series of events resulting in death, injury,
occupational illness, damage to or loss of equipment or property, or damage to the environment
• Incident Vs Accident
• Where have you heard of ‘risk’ referred to?
• Associated with negative outcomes: regret, losses, & damage
• Dictionary definition: ‘chance of bad consequences; expose to chance of injury or loss’
• An inherent risk in all activities: swimming in a pool Vs in ocean, working in your lab Vs in a coal mine
• Risk: consequence of the presence of hazards
• Hazard: a set of circumstances that may cause harmful consequences
• Any real or potential condition that can cause injury, illness, or death to personnel; damage to or loss
of a system, equipment or property; or damage to the environment (MIL STD 882D)
• Probability of it doing so, coupled with the severity of the harm, is the risk associated 6
 Let us understand safety (contd..)
• According to time horizons & severity: imminent risk & serious risk
• Can risk be eliminated? – Economic constraints - e.g. high end car for speedy driving
• Can injuries be prevented? – Need to understand the risk – Inherent/residual risk & entropic risk
• Risk associated with the degradation
• Is the presence of risk in itself a cause for concern? It is the degree of risk that matters
• Risk modeling/quantitative risk assessment – entropy model
• Perception of ‘safety’ centers on the level of the threat (to?)
• ‘Safe’ means that the dangers associated with a particular activity are ‘negligible’ & to make
something sufficiently safe means to reduce the risk to an ‘acceptable’ level
• Perceptions, tolerance of risk, & the circumstances
• Accidents continue to occur despite the best efforts to prevent them: ‘acceptable’ risk is a gray zone
• Degradation of a system factors (processes, technology, the physical environment & human
resources) is entropic risk: Degradation leads to higher risk levels!
• When shortcuts are taken, when technology is poorly maintained, when the physical environment
becomes deteriorated, & when people become inattentive, the likelihood of an accident rises
• Also introduces systemic inefficiencies (performance outcomes)
• Safety & performance are compatible goals & these don’t conflict
• Safety to be a priority - proactive in maintaining these systems
✓ Mol, T. (2003). Productive safety management. Routledge 7
 Why safety being overlooked?

• Sometimes only when several mistakes happen coincidentally would lead to a disaster.
• Since the probability is low, the risk is ignored.
• However, when all check points go wrong coincidentally, disaster becomes inevitable. If any one of
these can be eliminated, the tragedy could be avoided.

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Hazard, Risk & Intervention - Safety

INTERVENTION

Protecting from
the Shark is
intervention

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 Hazard Triangle
Hazard Triangle
Hazardous
Target/Threat
Element

Incident Causing Mechanism

Ericson, C. A. (2015). Hazard analysis techniques for system safety. John Wiley & Sons

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Hazard, Risk & Intervention - Safety

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Manuele, F. A. (2020). Advanced Safety Management: Focusing on Z10. 0, 45001, and Serious Injury Prevention. John Wiley & Sons

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 Risk Evaluation Matrix Initial risk – Residual risk

Risk = Probability X Severity

Unacceptable 10-20
Undesirable 8-9
Allowable 3-7
Acceptable 1-2
Acceptable Risk: “The risk for which the probability
of an incident or exposure occurring & the severity
of harm or damage that may result are as low as
reasonably practicable”
ALARP: “That low level of risk which can be further reduced only by an expenditure that is disproportionate in relation to the
resulting decrease in risk that would be achieved”
Manuele, F. A. (2020). Advanced Safety Management: Focusing on Z10. 0, 45001, and Serious Injury Prevention. John Wiley & Sons 13
 • Accident causation
models: why &
how
• Important
theoretical basis
for safety science
& important
method for
accident analysis
& prevention

Fu, G., Xie, X., Jia, Q., Li, Z., Chen, P., & Ge, Y. (2020). The development history of accident causation models in the past 100 years: 24Model, a more modern accident
causation model. Process Safety and Environmental Protection, 134, 47-82
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 The ‘Swiss cheese’ model of accident causation - concatenation of failures

• Reason, J. (2016). Organizational accidents revisited. CRC press

• Cumulative act effect

• Propounded by James T. Reason
• Organization's defenses against failure are modeled as a series of imperfect barriers, represented as slices of
Swiss cheese
• A trajectory of accident opportunity - A lining-up of the gaps & weaknesses creating a clear path through the
defences a defining feature of Orgax
• Active failures: unsafe acts – errors &/or procedural violations
• Latent conditions: Organizational factors, unsafe supervision, & preconditions for unsafe conditions
• Latent conditions: act like resident pathogens that combine with local triggers to open up an event trajectory
through the defences – Oxygen in case of fire – Similarly packaged drugs in the pharmacy 15
The ‘Swiss cheese’ model – Contd..

Basic ‘anatomy’ of an Orgax

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 Cause of the accident
strongly
Theoretical models emphasized Human error

Active failures/Unsafe acts Unsafe acts

Mental condition
Errors of worker
(Informational problems) Physical condition
Violations of worker
Skill-based Rule-based Knowledge-based
slips & lapses mistakes mistakes Erroneous/ Perceptual skills
unintended
Other individual-
Sabotage centered terms
Situational
Psychological
condition: change
In between
• Reason, J. (1990). Human error. Cambridge university press above 2
• Reason, J. (2016). Organizational accidents revisited. CRC press

Routine/habitual Exceptional

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Thank you!! Questions?