Industrial Safety Reports

The Industial Safety Reports series is published by the Institute and the Foundation for an Industrial Safety Culture.

It brings together work that is the result of research and studies carried out by ICSI's Discussion Groups. It looks in detail at various themes related to industrial safety such as consultation, trade-offs and human and organisational factors.

The Industrial Safety Reports series can be freely downloaded in PDF format. You can also find the entire collection in the Docsi repository.

Safety culture

Safety culture
From understanding to action
“Safety Culture” working group - 131 pages

This document is based on the ICSI working group’s work on safety culture and on discussions within the ICSI team. It provides an overview of the safety culture concept and the actions
possible to improve it. ICSI also presents its own choices, based on the abundant scientific literature compiled by the working group.
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Human and organisational factors of safety

Catastroph aversion
Social attitudes towards commom fates

Nicolas Treich, Christopher Rheinberger - 55 pages

In light of climate change and other existential threats, policy commentators sometimes suggest that society should be more concerned about catastrophes. This document reflects on what is, or should be, society's attitude toward such low-probability, high-impact events. The question underlying this analysis is how society considers
- a major accident that leads to a large number of deaths ;
- a large number of small accidents that each kill one person
where the two situations lead to the same total number of deaths.

We first explain how catastrophic risk can be conceived of as a spread in the distribution of losses, or a "more risky" distribution of risks. We then review studies from decision sciences, psychology, and behavioral economics that elicit people's attitudes toward various social risks. This literature review finds more evidence against than in favor of catastrophe aversion.

We address a number of possible behavioral explanations for these observations, then turn to social choice theory to examine how various social welfare functions handle catastrophic risk. We explain why catastrophe aversion may be in conflict with equity concerns and other-regarding preferences. Finally, we discuss current approaches to evaluate and regulate catastrophic risk, with a discussion of how it could be integrated into a benefit-cost analysis framework.

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The authors have undertaken a field study of daily decision-making processes in groups under uncertainty, in the health care domain. The work follows the tradition of naturalistic decision-making (ndm) research. It aims to understand how groups in this high reliability context conceptualize and internalize uncertainties, and how they handle them in order to achieve effective decision-making in their everyday activities.

In close cooperation with a teaching hospital in Austria, the authors have developed and tested a training course on group decision-making in the field of anesthesia and intensive care. The training course was intended to help participants improve their performance in group decision-making. Training was focused on acquiring the knowledge and experience successfully to make such decisions.

This report documents the last phases of the research projectDecision-making in groups under uncertainty, in which the authors propose an improvement to group decision-making procedures, in the form of a training course. It describes the development of the training course, its implementation, results obtained and improvements made based on feedback from practitioners.

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This document provides a short literature review on the complementarity (and antagonisms) between liability rules, safety regulation and insurance and their effect on safety management. It draws on a range of disciplines, with a focus on economic analysis of law and regulation theory. Some of the issues discussed are rather complex ; this document attempts to provide simple explanations together with references to the professional literature for the interested reader. Some issues are the subject of ongoing debate between scholars ; in such situations, we have attempted to present the various points of view.

The document provides background information concerning the topics discussed during the NeTWork'2012 workshop, and draws on some of the contributions of workshop participants and the rich discussion which took place during the three days.

The first chapter presents issues related to regulation, starting with the classical economic justifications for state intervention (presence of externalities, information failures and moral hazard). A number of obstacles to the effectiveness of safety regulation are presented. Finally, some alternatives or complements to regulation,
including self-regulation, are briefly discussed. Chapter 2 presents an overview of liability law, starting with some introductory definitions. Factors which weaken the effectiveness of liability as an incentive to invest in prevention are discussed, as are negative effects of liability regimes on safety management. A number of case
studies illustrating the liability of regulators are briefly presented. Chapter 3 discusses the impact of insurance and reinsurance on firms' and individuals' safety management. The last chapter briefly analyzes firms and individuals' sources of motivation to take care.

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A field study of groupe decision-making in health care
Juliane Marold, Ruth Lassalle, Dietrich Manzey, Markus Schöbel - 34 pages

The authors have undertaken a field study of daily decision-making processes in groups under uncertainty, in the health care domain. The work follows the tradition of naturalistic decision-making (NDM) research. It aims to understand how groups in this high reliability context conceptualize and internalize uncertainties, and how they handle them in order to achieve effective decision-making in their everyday activities.

The work is based on observations of a specific kind of health care meeting where treatment options for cancer patients are discussed, as well as on questionnaires completed by the participating physicians. The researchers have analyzed the strategies used by people to cope with uncertainty, including the order in which these strategies are used. The have analyzed characteristics of decisions where the decision-making process was judged by the experts involved to be "good" or "acceptable".

The work identifies a new source of uncertainty not found in previous NDM studies: divergent opinions held by decision-makers in the group. A strong hierarchy gradient in play during the meetings is perceived by group members as contributing to poor decision-making performance.
The authors, Juliane Marold, Ruth Lassalle, Dietrich Manzey (TU Berlin) and Markus Schöbel (Universität Basel, Suisse), suggest a number of techniques which could be used to improve decision-making performance.

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Leadership in safety, industrial practice
Working group "Leadership in safety" - 106 pages

The aim of this document is to help personnel responsible for operational units and members of the Health and safety committee3 to develop their leadership abilities in the domain of safety. The objective is to provide simple principles and practical examples that can be easily adapted to the individual context.

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Juliane Marold, Ruth Wagner, Dietrich Manzey, Markus Schöbel - 47 pages

The authors have studied daily decision-making processes in groups under uncertainty, with an exploratory field study in the medical domain. The work follows the tradition of naturalistic decision-making (NDM) research. It aims to understand how groups in this high reliability context conceptualize and internalize uncertainties, and how they handle them in order to achieve effective decision-making in their everyday activities. Analysis of the survey data shows that uncertainty is thought of in terms of issues and sources (as identified by previous research), but also (possibly a domain-specific observation) as a lack of personal knowledge or skill. Uncertainty is accompanied by emotions of fear and shame. It arises during the diagnostic process, the treatment process and the outcome of medical decision making.

The most frequently cited sources of uncertainty are partly lacking information and inadequate understanding owing to instability of information. Descriptions of typical group decisions reveal that the individual himself is a source of uncertainty when a lack of knowledge, skills and expertise is perceived. The group can serve as a source of uncertainty if divergent opinions in the decision making group exist. Three different situations of group decisions are identified: Interdisciplinary regular meetings (e.g. tumor conferences), formal ward meetings and ad hoc consultations. In all healthcare units concerned by the study, only little use of structured decision making procedures and processes is reported. Strategies used to handle uncertainty include attempts to reduce uncertainty by collecting additional information, delaying action until more information is available or by soliciting advice from other physicians. The factors which ultimately determine group decisions are hierarchy (the opinion of more senior medical staff carries more weight than that of junior staff), patients' interest and professional competence. Important attributes of poor group decisions are the absence of consensus and the use of hierarchy as the predominant decision criterion. On the other hand, decisions judged to be effective are marked by a sufficient information base, a positive discussion culture and consensus.

The authors identify four possible obstacles to effective decision making: a steep hierarchy gradient, a poor discussion culture, a strong need for consensus, and insufficient structure and guidance of group decision making processes. A number of intervention techniques which have been shown in other industries to be effective in improving some of these obstacles are presented.
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François Daniellou, Marcel Simard, Ivan Boissières - 118 pages

This document provides a state of the art in the human and organizational factors of industrial safety. It shows that integrating human factors in safety policy and practice requires that new knowledge from the social sciences (in particular ergnomics, psychology and sociology) be taken on board and linked to operational concerns.
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Enrico Zio, Nicola Pedroni - 61 pages

The authors introduce the general concepts, definitions and issues related to the use of Risk-informed decision-making (RIDM). These are structured processes which assist decision-makers when faced with high impact, complex decisions involving multiple objectives and the presence of uncertainty. They aim to ensure that decisions between competing alternatives are taken with an awareness of the risks associated with each option, and that all attributes of a decision are considered in an integrated manner. Motivations for the use of these techniques as a complement to more traditional deterministic approaches to risk assessment are provided.
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Enrico Zio, Nicola Pedroni - 50 pages

This document provides an overview of sources of uncertainty in probabilistic risk analysis. For each phase of the risk analysis process (system modeling, hazard identification, estimation of the probability and consequences of accident sequences, risk evaluation), the authors describe and classify the types of uncertainty that can arise. The document provides: a description of the risk assessment process, as used in hazardous industries such as nuclear power and offshore oil and gas extraction; a classification of sources of uncertainty (both epistemic and aleatory) and a description of techniques for uncertainty representation; a description of the different steps involved in a Probabilistic Risk Assessement (PRA) or Quantitative Risk Assessment (QRA), and an analysis of the types of uncertainty that can affect each of these steps; annexes giving an overview of a number of tools used during probabilistic risk assessment, including the HAZID technique, fault trees and event tree analysis.
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Risk analysis

The investigation process following major technological accidents
State of play and avenues for improvement
Discussion Group ‘The investigation process following major technological accidents - 74 pages

This Cahier de la sécurité industrielle analyses the question of how safety investigations are conducted in France following major technological accidents occurring in Seveso-type facilities. It is the outcome of the work of ICSI discussion group in which some 20 participants from very different backgrounds: trade union organisations and associations, regional communities, schools, universities, research institutes and centres, industrialists and industrial federations, and experts met over a period of two years.

From the analysis of international and multi-sectoral models, points of view put forward by the stakeholders of any initial plan and discussions between participants, this Cahier de la sécurité industrielle provides an overview of the safety investigation process, distinct from the judicial inquiry. Avenues for improvement are identified from the feedback compiled by the discussion group.

This document is intended for all stakeholders interested in industrial safety: representatives of public authorities, local communities, companies, trade union organisations and inter-professional organisations, associations of victims of a disaster, representatives of hygiene, security, environment (HSE) organisations, legal and insurance companies, etc. It will also be of interest to the academic community and students.
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Possibilistic methods for uncertainty treatment
Enrico Zio, Nicola Pedroni - 41 pages

Enrico Zio et Nicola Pedroni proposent ici une méthode pour évaluer la performance d'une politique de maintenance en intégrant l'effet de l'incertitude (durée d'équipements...).

Une étude de cas pratique, concernant la maintenance d'une soupape dans une turbo-pompe d'un système de lubrification d'une centrale nucléaire, permet d'illustrer la méthode.

Cette théorie permet de représenter l'incertitude épistémique (connaissance) de manière rigoureuse, sans introduire de biais, contrairement aux approches classiques de la propagation d'incertitude.

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Les auteurs analysent l'impact de différentes représentations de l'incertitude épistémique (liée à un manque de connaissances ou à la présence de données subjectives) sur des problèmes pratiques d'analyse de risque. Deux types de problème sont étudiés :
- l'estimation de mesures d'importance de composants en présence d'incertitudes épistémiques ;
- la propagation d'incertitudes dans un modèle employé pour analyser le risque inondation.

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Enrico Zio, Nicola Pedroni - 49 pages
This document provides a critical review of different frameworks for uncertainty analysis, in a risk analysis context: classical probabilistic analysis, imprecise probability (interval analysis), probability bound analysis, evidence theory, and possibility theory.The driver of the critical analysis is the decision-making process and the need to feed it with representative information derived from the risk assessment, to robustly support the decision. Technical details of the different frameworks are exposed only to the extent necessary to analyze and judge how these contribute to the communication of risk and the representation of the associated uncertainties to decision-makers, in the typical settings of high-consequence risk analysis of complex systems with limited knowledge on their behaviour.
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Éric Marsden - 20 pages

NeTWork's 2011 workshop, concerned Control and accountability in highly automated systems. The workshop was organized by Gudela Grote (ETH Zürich) and Johannes Weyer (TU Dortmund), and primarily funded by the Foundation for an Industrial Safety Culture (FonCSI); it brought together academic participants from multiple scientific disciplines and practitioners in several fields. It is the rich discussion between these participants which gave rise to the present document.

This document is a summary of the main issues discussed during the course of the workshop, focusing in particular on questions related to accountability. It aims to provide an overview of the questions most relevant to decision-makers and other interested parties, together with pointers to relevant academic literature.
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Copyright and licensing
The documents in the Industrial Safety Reports series are distributed under a BY-NC-ND Creative Commons licence. Under the terms of this licence you are free to reproduce, distribute and communicate the document under the following conditions:

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The Industrial Safety Reports have two ISSN numbers:
ISSN 2100-3874 for the print version and ISSN 2268-4174 for the online version.