Serious-incident prevention

Note-. This chapter was written by T. E. Bums, Quality Safety Edge, and based on his book Serious Incident Prevention, 2nd ed., Butterworth-Heinemann, Woburn, MA, 2002. 

Too often after an incident, managers find that critical work practices have been inappropriately altered or terminated. The effective measures of upstream performance indicators established by the serious-incident prevention process help ensure that critical actions are sustained for the long term. The establishment of effective feedback systems provides for timely adjustments to the safety process in proactive actions taken before the occurrence of an incident rather than reactive actions after damage has been done. 

The serious-incident prevention process model utilizes measurement and feedback systems as the basis for identifying appropriate reinforcement milestones and to provide early warning of a need for corrective actions. Adding positive reinforcement actions into the workplace helps ensure that employees feel genuinely appreciated when performance meets or exceeds expectations—a simple but powerful concept. Monitoring upstream performance indicators provides a further excellent opportunity to initiate preventive actions before serious incidents occur, rather than after the fact, as is so often the case when the employees have no rehable indication of upstream performance indicators. 

It is an old adage that what gets measured, gets done. Perhaps a more accurate statement is that what gets measured and reinforced, gets done. The reinforcement and feedback element of the serious-incident prevention process helps ensure that outstanding performance is recognized and early intervention is initiated when the need for adjustments to the prevention process is indicated. 

IMPLEMENTATION OF THE SERIOUS-INCIDENT PREVENTION PROCESS PIPELINE OPERATIONS CASE STUDY... 

One company s pipeline team, comprised of a first-level supervisor and other personnel responsible for operating and maintaining the pipeline system, established an objective of developing a more effective approach to serious-incident prevention based on the eight-element process model. The team s assessment of risks included evaluating causes of past U.S. pipeline accidents. Department of Transportation (DOT) data (Fig. 18.5) identify third-party damage as the most frequent cause of pipeline incidents, followed by defective equipment or repair, external corrosion, internal corrosion, and operator error. The team s thorough evaluation of potential risks has helped ensure that the appropriate tasks and safe... 

SPECIAL TOPICS SERIOUS-INCIDENT PREVENTION TABLE 18.1 Continued)... 

TABLE 18.2. Reinforcement Plan Pipeline Operations Serious-Incident Prevention... 

Serious-incident prevention process fully developed Pipeline team First-level supervisor and department head... 

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