199 East Badger Road, Suite 200, Madison, WI 53713
Call Us Today: 608-260-7468


15 Aug
Applying Predictive Analytics in Safety

In recent years, companies have been generating vast and ever-increasing amounts of data associated with business operations. This trend has led to renewed interest in predictive analytics, a field which focuses on analyzing large data sets to identify patterns and predict outcomes to help guide decision-making. While many leading companies use predictive analytics to identify marketing and sales opportunities, similar data analysis strategies are less common in occupational and process safety. Although the use of predictive analytics is less common in the field of safety, the potential benefits of analyzing safety data are considerable.

Just as companies are currently using customer data to predict customer behavior, safety and incident data can be used to predict when and where incidents are likely to occur. Appropriate data analysis strategies can also identify the key factors that contribute to incident risk, thereby allowing companies to proactively address those factors to avoid future incidents.

Predictive Analytics: In Theory

Let’s take a step back and look at what predictive analytics is and what it does. Predictive analytics is a broad field encompassing aspects of various disciplines, including machine learning, artificial intelligence, statistics, and data mining. Predictive analytics uncovers patterns and trends in large data sets for the purpose of predicting outcomes before they occur. One branch of predictive analytics, classification algorithms, could be particularly beneficial to industry, especially when it comes to avoiding incidents.

Classification algorithms can be categorized as supervised machine learning. With supervised learning, the user has a set of data that includes predictive variable measurements that can be tied to known outcomes. The algorithms identify the relationships between various factors and those outcomes to create predictive rules (i.e., a model). Once created, the model can be given a dataset with predictive variable measurements and unknown outcomes, and will then predict the outcome based on the model rules.

Predictive Analytics: In Practice

Like many in the transportation industry, this railroad had experienced a number of derailments caused by broken rails. Broken rail derailments can have particularly severe consequences, since they typically occur on mainline tracks, at full speed, and with no warning of the impending broken rail. Kestrel was asked to create a predictive model of track-caused derailments on a mile-by-mile basis to identify areas of high broken rail risk so the railroad could target those areas for maintenance, increased inspections, and capital improvement projects.

Penalized Likelihood Logistic Regression

As described above, classification models learn predictive rules in an original data set that includes known outcomes, then apply the learned rules to a new data set to predict outcomes and probabilities. In this case study, Kestrel used a logistic regression modified by Firth’s penalized likelihood method to:

  • Fit the model
  • Identify eleven significant predictive variables (based largely on past incidents)
  • Calculate broken rail probabilities for each mile of mainline track based on track characteristics

Final Model

The final model calculates a predicted probability of a broken rail occurring on each mile of track over a two-year period. The results suggest that the final model effectively predicted broken rail risk, with 33% of broken rails occurring on the riskiest 5% of track miles and 70% occurring in the riskiest 20%. Further, the model shows that the greatest risk reduction for the investment may be obtained by focusing on the 2.5% of track miles with the highest probability of a broken rail. This ability to predict where broken rails are likely to occur will allow the company to more effectively manage broken rail derailment risk through targeted track inspections, maintenance, and capital improvement programs.

Implications for Other Industries

The same general approach described in the above case study can also be applied to other industries—using KPIs to determine predictive variables and incidents as the outcome. The process is as follows:

  • Measurements for defined variables would be taken regularly at each facility or unit. Precision increases as the measurements become more frequent and the observed area (facility/unit) becomes smaller.
  • Once a sufficient number of measurements has been taken, they would then be combined with incident data to provide both the predictive variable measurements and the outcome data needed for training a model. This dataset would be fed into a logistic regression or other classification algorithms to create a model.
  • Once the model has been created, it can be applied to new measurements to predict the probability of an incident occurring at that location during the applicable timeframe.

Once predicted incident probabilities have been found, management would be able to focus improvement resources on those locations that have the highest probabilities of experiencing an incident. The classification algorithms also identify which factors have predictive validity, so management will know how improving those factors will affect the predicted probability of incidents occurring. In other words, they will know which factors have the strongest relationship with incidents and can focus on improving those first.

Data-Driven Decisions

Industrial companies are generating and recording unprecedented amounts of data associated with operations. Those that strive to be best-in-class need to use that data intelligently to guide future business decision-making.

The versatility of predictive analytics, including the method described in this case study, can be applied to help companies analyze a wide variety of problems. In this way, companies can:

  • Explore and investigate past performance
  • Gain the insights needed to turn vast amounts of data into relevant and actionable information
  • Create statistically valid models to facilitate data-driven decisions
22 Jun
Q&A: The New ISO 45001 Standard

What is ISO 45001?

ISO 45001 is a new international standard created by the International Organization for Standardization (ISO) that specifies requirements for an occupational, health & safety management system (OHSMS). It provides a framework for managing the prevention of death, work-related injury, and work illnesses. The ultimate goal of the standard is to help organizations proactively improve OHS performance and create a safe and healthy workplace.

Note that ISO 45001 provides guidance. It does not state specific criteria for OHS performance, nor is it prescriptive about the OHSMS design. It is a management tool for voluntary use by organizations to minimize OHS risks.

Why Is ISO 45001 necessary?

There are several reasons why the creation of an international standard to manage OHS performance is necessary:

  • First and foremost, organizations are responsible for minimizing the risk of harm to all individuals that may be impacted by their activities. The standard aims to protect human lives by encouraging organizations to create a safer, healthier workplace.
  • According to the International Labour Organization (ILO), there were 2.34 million deaths worldwide in 2013 as a result of worker activities. The greatest majority (2 million) are associated with health issues, as opposed to injuries. The economic burden associated with this number of occupational injuries and illnesses is significant. Organizations must manage all their risks—including OHS—to survive. Poor OHS management can result in loss of key employees, business interruption, claims, higher insurance premiums, regulatory action, reputational damage, loss of investors, and loss of business.
  • Finally, increased globalization creates new OHS challenges. ISO 45001 is an international standard that promotes global conformity.

What are the key aspects of ISO 45001?

Many of the elements of ISO 45001 are the same or similar to those found in OSHAS 18001. However, there are additions and changes in ISO 45001 that differentiate the new standard.ISO 45001 Hierarchy of Controls

ISO 45001 establishes new roles for the organization’s people. First, it emphasizes worker participation in the OHSMS. This includes ensuring that workers are competent and have the appropriate skills to safely perform their tasks. Second, the role of top management is different than in OHSAS 18001. Of note, a designated Management Representative is no longer required; however, those individuals in management roles are expected to take ownership and demonstrate a commitment to OHS through leadership. Top management must demonstrate direct involvement and engagement with the OHSMS by:

  • Ensuring the organization’s OHS policy and objectives are compatible with the overall strategic direction of the organization
  • Integrating OHSMS processes and requirements into business processes
  • Developing and promoting an OHS culture that supports the OHSMS
  • Being accountable for the OHSMS’s effectiveness

In addition to people, ISO 45001 follows a risk-based approach that advocates prevention. This requires identifying activities that could harm those working on behalf of the organization. A large part of this involves understanding the “context” of the organization, another new element of ISO 45001. Organizations must be able to identify all external and internal factors that have the potential to impact OHS management objectives and results.

To address risks and opportunities, there are new clauses related to hazard identification, as well. As with other sections of the standard, hazard identification becomes a process rather than a procedure and, importantly, considers all individuals near the workplace who may be impacted by the organization’s activities. ISO 45001 further outlines a more defined hierarchy for organizations to determine appropriate controls.

How does ISO 45001 fit in with other ISO standards and management system approaches?

ISO 45001 follows the same high-level management system approach being applied to other ISO management system standards (e.g., ISO 14001 and ISO 9001)—Annex SL. Because of this, the ISO 45001 requirements should be consistent with the other standards to allow for relatively easy alignment and integration into the organization’s overall management processes.

In addition, ISO 45001 takes into account other OHS standards, including OHSAS 18001, ILO-OSH Guidelines, various national standards, and the ILO’s international labor standards and conventions.

What is Annex SL?

As mentioned above, Annex SL is the structure for all new and revised ISO standards. It defines the framework for a generic management system—and is then customized for each discipline. This standard structure allows for easier integration between management systems and improved efficiencies. The major clauses for all ISO management system standards are identical under Annex SL and fall into the Play-Do-Check-Act (PDCA) cycle. Organizations who have already implemented ISO 9001:2015 or ISO 14001:2015 will be familiar with the Annex SL structure.

The table below outlines the main clauses in Annex SL, as well as the OHSMS-specific clauses. Highlighted areas indicate those sections that are significant changes/additions to the existing OHSAS 18001 standard.ISO 45001 Table

What does this mean for OHSAS 18001?

As outlined in the table above, ISO 45001 does not conflict with OHSAS 18001. In fact, it expands and enhances the existing standard to improve integration of the OHSMS into the overall business. Once it is finalized, ISO 45001 is intended to replace OHSAS 18001. Much like other management system standards, current users of OHSAS 18001 will need to update their systems according to the requirements of the new standard within a three-year transition period.

When will it be finalized?

The current expected publication date is February 2018. Drafts will be available through local ISO members once they reach the public inquiry (DIS) stage and Final Draft (FDIS) stage.

Once it’s published, who should use ISO 45001?

The short answer is everyone. ISO 45001 is designed to be a flexible management system that can be implemented by any organization, no matter the size, type, or industry. As long as the organization has people who may be affected by its activities, an OHSMS has value in ensuring worker health and safety and fulfilling legal requirements.

Why should I do this? Why are management systems like ISO 45001 beneficial?

A management system is an organizing framework that enables companies to achieve and sustain their operational and business objectives through a process of continuous improvement. A management system is designed to identify and manage risks through an organized set of policies, procedures, practices, and resources that guide the enterprise and its activities to maximize business value. There are a number of reasons to implement a management system (see this article: https://kestrelmanagement.com/business-benefits-mgmt-sys/).

What do I do next?

  • Get informed! Start reading up on ISO 45001. While the final standard may not yet be published, current versions can provide a good indication of what is to come.
  • Identify gaps in your existing OHSMS that will need to be addressed to meet any new requirements. If you don’t have an existing OHSMS, review the requirements and determine what pieces you may already have in place.
  • Develop an implementation plan. There is a three-year transition period once the new ISO 45001 standard is published (anticipated February 2018). Plan according to this timeline.
  • Provide training. It is vital to ensure that workers and management are engaged in the OHSMS and that they are competent in any new skills/responsibilities that may be required.
  • Put your plan into action. Update/develop your OHSMS to meet the ISO 45001 requirements and provide verification of its effectiveness to ensure certification.
01 Jun
Don’t Miss Kestrel at the EHS Seminar in Galveston

Join Kestrel at the 30th annual EHS Seminar next week to hear A.W. Armstrong present on Using a Data-Driven Method of Accident Analysis: A Case Study of the Human Performance Reliability (HPR) Process.

EHS Seminar
June 5-8, 2017
Moody Gardens Convention Center
Galveston, Texas
Kestrel Presentation: Thursday, June 8 at 8:30 a.m.
Kestrel Booth: #611

The Role of Human Error in Occupational Incidents

The concept of human error and its contribution to accidents and incidents have received considerable research attention in recent years. When an accident/incident occurs, investigation and analysis of the human error that led to the incident often reveals vulnerabilities in an organization’s management system.

This recent emphasis on human error has resulted in an expansion of knowledge related to human error and the most common factors contributing to incidents. Kestrel’s Human Performance Reliability (HPR) process helps to classify human error—with the additional step of associating the control(s) that failed to prevent the incident from occurring. This process allows organizations to identify how and where to focus resources to drive safety performance improvements.

In this presentation, A.W. describes Kestrel’s method for identifying the most frequent human errors and most problematic controls and presents a case study wherein HPR was applied to a large petroleum refining company.

Catch Up with Kestrel

In addition to the presentation on June 8, Kestrel’s experts will also be available in the exhibit hall (booth #611) to discuss HPR, as well as our holistic approach to the management of process safety.

We welcome the opportunity to meet with you, learn more about your needs, and discuss how Kestrel helps our clients:

  • Improve occupational and process safety performance
  • Manage EHS and quality risks
  • Achieve regulatory compliance assurance

See you at booth #611 in Galveston!

18 Apr
Process Safety Competence Assurance

Organizations in the chemical manufacturing and energy industry face the daily challenge to safely manage the processing, storage, and transportation of hazardous materials. To enable this, a great deal of focus and effort is put into compliance, strong management systems, well-maintained equipment, and organizational capability.

A key component of organizational capability is the competence of employees. This is critical to an organization’s success—and very relevant to process safety. In fact, process safety competence is both a regulatory requirement and a business improvement driver. But what does competence mean when it comes to the management of process safety?

Defining Competence

Process safety competence is an area that is sometimes misunderstood as simply providing training to employees. However, it is much more. Organizations need to understand the definition of competence and ensure employees have the basic competence required to fulfill their job function successfully.

Competence is often defined as “an individual having the right level of training and experience to enable the successful execution of defined job responsibilities”. By this definition, competence is a step beyond basic job training—one that necessitates understanding and the ability to successfully apply what is learned.

To fulfill this intent, especially for those working on the management of process safety, it is critical that employers have a structured and sustainable approach to ensure process safety competence. This may include a clear process safety competence assurance program. Not only will this assist with regulatory compliance, it is a critical element in the prevention of a process safety incident.

Steps to Ensure Competence

To successfully create an organizational culture that values and emphasizes process safety competence assurance, there are some basic steps that need to be followed, including those outlined below:

  • Understand and define positions within the organization that impact or influence process safety.
  • Define desired competence levels and requirements for each of these positions.
  • Develop an organizational competence matrix for process safety that documents the positions and requirements.
  • Assess position holders’ (i.e., employees’) process safety competence against the requirements outlined on the organizational matrix.
  • Identify gaps in competence for each individual and develop individual closure plans.
  • Work with employees to address identified competency gaps and verify that they have been closed.

When filling a position that has process safety requirements, the identified candidate(s) should undergo an assessment against the defined process safety requirements for the position to ensure they are competent. It is important to ensure the new employee has the required competence before they are appointed or hired. Successful candidates may have some minor gaps that can quickly be rectified, but putting candidates into jobs that impact or influence process safety as “development” or a “learning opportunity” is a large risk to the organization and unfair to the individual. It is also a practice organizations should stop if they are truly committed to process safety.

Maintaining the Commitment to Competence

To further enhance the ongoing process safety competence of an organization, each position that impacts or influences process safety must maintain the required process safety competencies identified on the competence matrix. The commitment must be sustained to be successful; it should not be a one-time effort.

Organizations can do this by:

  • Reviewing competence requirements and adjusting the matrix as new requirements are identified;
  • Conducting regular assessments to verify employee competence; and
  • Providing opportunities for training and experiential learning that ensure process safety competence remains a top priority.
04 Apr
OSHA Releases Three New PSM Publications

OSHA has released three new guidance documents to help employers comply with the agency’s Process Safety Management (PSM) standard. PSM is critically important to facilities that store highly hazardous chemicals. Implementing the required safety programs helps prevent fires, explosions, large chemical spills, toxic gas releases, runaway chemical reactions, and other major incidents. The new documents focus on PSM compliance for Small BusinessesStorage Facilities and Explosives and Pyrotechnics Manufacturing.

15 Feb
Improving Process Safety Leadership and Culture

Over the past 30 years, there have been numerous events both nationally and internationally that have led organizations to bring a more concerted focus to process safety. Such a focus has many such organizations building process safety elements into their management systems. The goal is to not only comply with regulations, such as OSHA 1910.119, but to also ensure sustainable programs that prevent process safety incidents from ever happening.

A large part of this effort involves integrating process safety leadership into existing programs. Improving an organization’s process safety leadership and culture can have significant and lasting impacts on a company’s process safety performance. Three steps that organizations can undertake to advance this effort include the following:

  • Amending metrics to include more leading indicators that are designed to prevent process safety incidents
  • Cultivating communications geared toward process safety
  • Ensuring incentive schemes include measures related to process safety

Traditional Management Systems

Traditional management systems include personal safety, environmental management, and industrial hygiene as the core elements. Management systems, metrics, and communications have historically been focused on personal safety and environmental management. These areas have clear industry compliance drivers and easy-to-understand metrics for organizational leaders. The prevention of personal injury or actions to protect the environment are relatable concepts for most.

The addition of process safety to the management system structure has been a smooth transition for many organizations, as the majority of the elements that cover process safety are already part of a typical management system. However, process safety—and the incidents that can occur if not managed well—can be complex in nature to explain. The challenging part of integrating process safety into an organization becomes getting leaders both comfortable and equipped to address it.

Leading Metrics

Due to the generally low frequency of process safety incidents, the development and measurement of process safety indicators is often not a priority for organizations. Many companies rely heavily on lagging personal safety and environmental metrics (Days Away from Work Rate, Total Recordable Incident Rate, Spill Rate). Injuries are easy for leaders to understand and explain. Leaders demonstrate empathy towards their staff and contractors, again making it easier for them to relate to personal safety. Minor spills are also easily understood and easier to discuss.

While these lagging metrics are still important and can be used and communicated, organizations need to include different metrics to bring more focus on leading indicators that are designed to prevent process safety incidents. Some examples of leading metrics that can be developed, implemented, and tracked include the following:

  • Identifying systems/equipment that are critical to prevent or mitigate a process safety event, and tracking their effectiveness and operability
  • Tracking the completion of Management of Change (MOC)
  • Tracking the effective closeout of Process Hazard Analysis (PHA) and PSM audit actions
  • Assessing organizational capability around process safety and tracking identified gap closure plans
  • Tracking the number of Pressure Relief Valve (PRV) activations
  • Tracking anomalies from complete permit-to-work reviews


Once an organization has developed a set of leading process metrics applicable to the business, the metrics should be made visible to all staff and included in communications on business performance. Leaders also need to focus more of their strategic communications and site visits on process safety. This can include talking about leading process safety metrics and undertaking the following activities when at a facility:

  • Ask members of the facility staff about the major identified hazards from the PHA
  • Determine if staff are involved in reviewing and updating operating procedures
  • Ask staff about the last emergency drill and actions taken
  • Ask operations staff about the number of alarms they deal with on a typical shift to determine if alarm management/rationalization is required or if low criticality alarms are not burdening staff
  • Hold discussion groups focused on process safety during leadership onsite visits

Incentive Schemes

Another outcome of tracking lagging metrics involves translating them into part of the organization’s incentive bonus criteria for leaders. Organizations should work to transition leadership bonus/incentive schemes away from just traditional personal safety and environmental lagging metrics, namely injury and spill rates. Again, it would not be necessary to immediately drop existing lagging metrics. Start with adding the new metrics and gradually change the percentage weightings so leading process safety indicators become the dominant factor. This will serve to reinforce the importance of process safety and incident prevention in overall business performance.

To truly have an organization that demonstrates process safety leadership and has a strong process safety culture, there need to be some changes and effective actions taken. The steps outlined in this article—amending metrics, cultivating communications toward process safety, and integrating process safety into incentive schemes—can help organizations take a few of the initial necessary steps to build process safety culture and leadership and, ultimately, prevent process safety incidents from occurring.

06 Jan
Now Hiring: Process/Technical Safety Consultant

Due to continued expansion, Kestrel Management is seeking an experienced Consultant with a strong background in process/technical safety to join our team. The ideal candidate will have knowledge of current PSM regulations and RAGAGEP, with experience in their application to the petrochemical industry. Recent experience and sustained performance in a consulting environment working with multiple clients are preferred.

Read the full job description.

01 Dec
Final Rule: Walking-Working Surfaces

OSHA has issued a final rule updating its general industry Walking-Working Surfaces standard to protect workers from slip, trip, and fall hazards. The rule also increases consistency in safety and health standards for people working in both general and construction industries.

The final rule’s most significant update is allowing employers to select the fall protection system that works best for them, choosing from a range of accepted options including personal fall protection systems.

OSHA estimates the final rule will prevent more than 5,800 injuries a year. The rule takes effect Jan. 17, 2017.

Read the full press release.

10 Oct
Applying Predictive Analytics to Process Safety Leading Indicators

Leading indicators can be defined as safety-related variables that proactively measure organizational characteristics with the intention of predicting and, subsequently, avoiding process safety incidents. Leading indicators become especially powerful when combined with advanced statistical methods, including predictive analytics.

Case Study

Kestrel developed a major incident predictive analytical model for the transportation industry that is also applicable to the process industries. Using regularly updated inspection data, the model was created to provide major incident probabilities for each transportation segment over a six-month period.

Additionally, the model identifies the variables that are significantly contributing to major incidents, thereby showing the company which factors to address to prevent future incidents. Model validation revealed that it could successfully predict the location and time frame of 75% of major incidents.

Broader Applicability

Companies in the process industries are generating and recording unprecedented amounts of data associated with operations. Companies that strive to be best-in-class need to use that data intelligently to guide future business decision-making.

The versatility of predictive analytics, including the method described in this case study, can be applied to help companies analyze a wide variety of problems. In this way, companies can:

  • Explore and investigate past performance
  • Gain the insights needed to turn vast amounts of data into relevant and actionable information
  • Create statistically valid models to facilitate data-driven decisions

Join Kestrel at the 2016 International Symposium

Kestrel’s William Brokaw will be presenting the case study discussed above on Tuesday, October 25 at 1:15 p.m. at the Mary Kay O’Connor Process Safety Center 2016 International Symposium: Applying Predictive Analytics to Process Safety Leading Indicators.

MKOPSC 2016 International Symposium
October 25-27, 2016
Hilton Conference Center
College Station, Texas

Kestrel’s experts will also be on hand throughout the Symposium to talk with you. Stop by and see us at our booth. We welcome the opportunity to learn more about your needs and to discuss how we help our chemical and oil & gas clients manage environmental, safety, and quality risks; improve safety performance, and achieve regulatory compliance assurance.

15 Aug
Process safety programs the work for you.
Process Safety Management and Human Performance Reliability

On August 6, 2012, the release of flammable vapor led to a fire at the Chevron Refinery in Richmond, California. That event generated significant public concern about refinery safety and emergency response in California. It also eventually prompted California’s Department of Industrial Relations (DIR) to develop a draft regulatory proposal for a new Cal/OSHA Process Safety Management (PSM) standard that strengthens regulatory oversight, policy, and enforcement. The PSM for petroleum refineries notice hit the California Register on Friday, July 15, 2016.

But California refineries are not alone. Federal changes are on the way, as well, as OSHA considers revisions to its PSM standard.

Proposed Cal/OSHA Process Safety Management (PSM) Standard Changes

As a recap, the proposed Cal/OSHA PSM changes modify existing PSM language and introduce a number of new management system elements and other requirements. These amendments require California refineries to commit to the following:

  • Use the Hierarchy of Hazard Controls to choose safer, more enduring technologies that address safety concerns and help to eliminate or minimize hazards in refinery processes.
  • Perform damage mechanism reviews to assess physical degradation, such as corrosion and mechanical wear, and to determine recommended corrective actions.
  • Conduct safeguard protection analysis to ensure that safeguards will help prevent initiating events from turning into major catastrophes.
  • Implement corrective actions with clear and enforceable deadlines and consequences for inaction to ensure that safety program improvements are carried out.
  • Implement appropriate Management of Change (MOC) activities so safety is factored into changes to operations, maintenance procedures, personnel, etc., all of which can undermine plant safety.
  • Perform periodic safety culture assessments to evaluate management’s and employees’ attitudes, perceptions, and values as they pertain to safety.
  • Account for human factors (e.g., training and competency levels, fatigue, experience, communication, physical challenges), which can greatly influence accidents and incidents in the workplace.
  • Conduct root cause analysis to identify underlying causes of the incident and recommended corrective actions to help prevent recurrence.
  • Engage employees at all levels in all elements of the PSM program, including working to prevent accidents and incidents through the means described above.

The Human Element of PSM

Employee and contractor performance is a significant source of risk within any organization.  The majority of accidents and other unintended events are—at least in part—the result of human error. It is not surprising that Cal/OSHA’s proposed PSM regulations and potential Federal PSM changes recognize the importance of the “human element” in a number of the changes—from performing safety culture assessments to account for human factors, to engaging employees.

Many companies struggle with the following challenges as they work to establish and/or improve elements of their PSM programs:

  • How do we identify factors contributing to incidents?
  • What are appropriate recommendations that will drive improvements?
  • How should we include human factors in Process Hazard Analyses (PHAs)?
  • How can we improve our safety culture?

Often, these elements are treated independently, but this overlooks the important relationship between them. For example, any unintended event (e.g., an LOPS, process upset, safety incident) is the result of multiple contributing factors, not a single event. Focusing on these contributing factors enables companies to develop a deeper understanding of why incidents are occurring. Linking contributing factors to specific barriers further allow companies to identify weaknesses in their processes and procedures and to develop appropriate recommendations to drive improvements. Conducting contributing factor analyses also enables the company to identify specific human factors to be used in their PHAs.

Human Performance Reliability (HPR) Approach

Kestrel’s Human Performance Reliability (HPR) approach provides an integrated solution for addressing new PSM requirements. Unlike a typical root cause analysis, which addresses factors leading to a specific incident, HPR is based on a sophisticated statistical analysis of human factor data obtained from multiple incidents. This allows companies to identify and access broader—and potentially systemic—issues that are affecting the safety performance of the organization.

HPR consists of three elements:

  • Incident Investigation and Analysis (IIA) – IIA adopts the framework provided by the Human Factors Analysis and Classification System (HFACS) to classify human error and other contributing factors—but with the additional step of associating the control(s) that failed to prevent the incident from occurring. Statistical analyses help to identify patterns in the data to pinpoint the human errors and controls that are appearing most frequently.
  • Procedure Improvements – Although the IIA process will identify where improvements are needed (i.e., which controls are associated with incidents), it will not result in improved safety performance—not without completing associated improvement projects. Only by scoping and implementing those improvement projects will companies realize improved safety performance.
  • Safety Culture Assessment – Learning organizations actively seek the underlying causes of incidents and use data to make performance improvements. These organizations typically have robust systems to ensure that the traits that represent a strong safety culture are in place, mature, and fully integrated into standard practices

While the individual elements can be very helpful to a company, deploying them in tandem provides the richest and most comprehensive benefit to overall safety performance. That is because the three components are inherently complementary; each improves the effectiveness of the others.

Systemic Improvements

This process provides immediate value when applied to the investigation of an individual event by identifying additional factors that may have been missed following a traditional root cause analysis approach. It is most powerful, however, when data from multiple events are aggregated. The results of multiple investigations yield a pattern of human factor indicators that can be used to uncover system opportunities for PSM and operational enhancements and overall improved reliability.

  • 1
  • 2