HarpurHill,BuxtonDerbyshire,SK179JNT:+44(0)1298218000F:+44(0)1298218590W:www.hsl.gov.ukTheCausesofMajorHazardIncidentsandHowtoImproveRiskControlandHealthandSafetyManagement:AReviewoftheExistingLiteratureHSL/2006/117ProjectLeader:JulieBellAuthor(s):JulieBell&NicolaHealeyScienceGroup:HumanFactors©Crowncopyright(2006)iiCONTENTS1INTRODUCTION.........................................................................................11.1Background.............................................................................................11.2Objectives................................................................................................12METHODOLOGY........................................................................................33FINDINGSFROMTHELITERATUREREVIEW.........................................43.1Thecausesattribuedtomajorhazardincidents......................................43.2Controlmeasuresandbehaviourstopreventmajorhazardincidents.....93.3Safetyrelatedbehavioursthatneedtobechangedtopreventmajorhazardincidents...............................................................................................183.4Themosteffectivewaysofchangingbehaviour....................................213.5Impactoforganisationalchangefactorsoneffectiveriskcontrolandsafetymanagement..........................................................................................253.6Additionalrequirementsforpreventingmajorhazardincidents.............283.7Utilityofcurrentreportingsystemstoidentifyprobablecausesofmajorhazardindcidents.............................................................................................293.8WhereHSEshouldtargetitsresources.................................................304CONCLUSIONS........................................................................................334.1Theexistingevidencebase...................................................................334.2Possiblegapsintheevidencebaseandsuggestionsforhowtheycouldbeaddressed....................................................................................................344.3RecommendationsforHSEinterventions..............................................365BIBLIOGRAPHY.......................................................................................376APPENDIXA:MAJORACCIDENTCASESTUDIES..............................416.1Offshore.................................................................................................416.2Nuclear..................................................................................................446.3Chemical................................................................................................486.4Rail........................................................................................................506.5Air..........................................................................................................526.6Coalmining............................................................................................557APPENDIXB:SUMMARYOFREVIEWPAPERS...................................57iiiEXECUTIVESUMMARYIntroductionTheHealthandSafetyExecutive(HSE)commissionedtheHealthandSafetyLaboratory(HSL)tocarryoutareviewoftheexistingliteratureonthecausesofmajorhazardincidentsandtherelevantcontrolmeasuresandbehavioursthatcanpreventincident...
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