ACCIDENT PRECURSOR ANALYSIS AND MANAGEMENT

Reducing Technological Risk Through Diligence

James R. Phimister, Vicki M. Bier, Howard C. Kunreuther, Editors

NATIONAL ACADEMY OF ENGINEERING OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
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Accident Precursor Analysis and Management: Reducing Technological Risk Through Diligence ACCIDENT PRECURSOR ANALYSIS AND MANAGEMENT Reducing Technological Risk Through Diligence James R. Phimister, Vicki M. Bier, Howard C. Kunreuther, Editors NATIONAL ACADEMY OF ENGINEERING OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Accident Precursor Analysis and Management: Reducing Technological Risk Through Diligence THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, D.C. 20001 NOTICE: This publication has been reviewed according to procedures approved by a National Academy of Engineering report review process. Publication of signed work signifies that it is judged a competent and useful contribution worthy of public consideration, but it does not imply endorsement of conclusions or recommendations by the NAE. The interpretations and conclusion in such publications are those of the authors and do not purport to represent the views of the council, officers, or staff of the National Academy of Engineering. Funding for the activity that led to this publication was provided by: National Science Foundation, Public Entity Risk Institute, U.S. Nuclear Regulatory Commission, and National Aeronautics and Space Administration. International Standard Book Number 0-309-09216-7 (Book) International Standard Book Number 0-309-53218-3 (PDF) Library of Congress Catalog Card Number 2004110743 Copies of this report are available from National Academies Press, 2101 Constitution Avenue, N.W., Lockbox 285, Washington, D.C. 20055; (800) 624-6242 or (202) 334-3313; Internet, http://www.nap.edu. Printed in the United States of America Copyright 2004 by the National Academies. All rights reserved.

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Accident Precursor Analysis and Management: Reducing Technological Risk Through Diligence THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chairman and vice chairman, respectively, of the National Research Council. www.national-academies.org

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Accident Precursor Analysis and Management: Reducing Technological Risk Through Diligence COMMITTEE ON ACCIDENT PRECURSORS VICKI BIER, co-chair, University of Wisconsin, Madison HOWARD KUNREUTHER, co-chair, University of Pennsylvania, Philadelphia JOHN F. AHEARNE, Sigma Xi, Research Triangle Park, North Carolina ROBERT FRANCIS, Zucker, Scoutt and Rasenberger, Washington, D.C. HAROLD S. KAPLAN, Columbia Presbyterian Medical Center, New York, New York HENRY MCDONALD, University of Tennessee, Chattanooga ELIZABETH MILES, Johnson and Johnson, New Brunswick, New Jersey ELISABETH PATÉ-CORNELL, Stanford University, Stanford, California NAE Staff JAMES R. PHIMISTER, J. Herbert Hollomon Fellow, Program Office PROCTOR REID, Associate Director, Program Office NATHAN KAHL, Senior Project Assistant, Program Office CAROL R. ARENBERG, Managing Editor

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Accident Precursor Analysis and Management: Reducing Technological Risk Through Diligence Preface Almost every year there is at least one technological disaster that highlights the challenge of managing technological risk. On February 1, 2003, the space shuttle Columbia and her crew were lost during reentry into the atmosphere. In the summer of 2003, there was a blackout that left millions of people in the northeast United States without electricity. Forensic analyses, congressional hearings, investigations by scientific boards and panels, and journalistic and academic research have yielded a wealth of information about the events that led up to each disaster, and questions have arisen. Why were the events that led to the accident not recognized as harbingers? Why were risk-reducing steps not taken? This line of questioning is based on the assumption that signals before an accident can and should be recognized. To examine the validity of this assumption, the National Academy of Engineering (NAE) undertook the Accident Precursors Project in February 2003. The project was overseen by a committee of experts from the safety and risk-sciences communities. Rather than examining a single accident or incident, the committee decided to investigate how different organizations anticipate and assess the likelihood of accidents from accident precursors. The project culminated in a workshop held in Washington, D.C., in July 2003. This report includes the papers presented at the workshop, as well as findings and recommendations based on the workshop results and committee discussions. The papers describe precursor strategies in aviation, the chemical industry, health care, nuclear power and security operations. In addition to current practices, they also address some areas for future research. Using accident precursors to predict and prevent accidents is not a new idea. Two industry programs, the Accident Sequence Precursors Program overseen by

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Accident Precursor Analysis and Management: Reducing Technological Risk Through Diligence the U.S. Nuclear Regulatory Commission and the Aviation Safety Reporting System operated by the National Aeronautics and Space Administration, have been in existence for several decades; many other industry-specific programs have been established since those programs were started. Research has also been under way for several decades, some of which was highlighted in two earlier workshop publications, Near-Miss Reporting as a Safety Tool (Van der Schaaf et al., 1991) and Accident Precursors and Probabilistic Risk Assessment (Bier, 1998). Indeed, research results have increasingly been incorporated into practice. Nevertheless, a reassessment and affirmation of the objectives, challenges, limitations, and opportunities of precursor strategies is in order. This report is intended to address that need. STATEMENT OF TASK The committee was asked to meet two objectives: (1) to provided a common lexicon and framework for precursors with cross-industry applicability; and (2) to document and highlight the success of systems that have benefited from precursor information. The committee attempted to facilitate cross-industry communication and suggest tools and terminology (see Appendixes A and D) to encourage dialogue but did not espouse a particular definition of precursors, a particular framework, or a specific approach. The keynote speakers provided an overview of the issues of precursor management (Section II); subsequent speakers discussed how different approaches could be used for risk assessment (Section III), risk management (Section IV), and for linking risk assessment and risk management on an organizational or national level (Section V). REFERENCES Bier, V.M., ed. 1998. Accident Sequence Precursors and Probabilistic Risk Assessment. Madison, Wis.: University of Wisconsin Press. Van der Schaaf, T.W., D.A. Lucas, and A.R. Hale. 1991. Near-Miss Reporting as a Safety Tool. London: Butterworth-Heinemann.

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Accident Precursor Analysis and Management: Reducing Technological Risk Through Diligence Acknowledgments This report reflects the contributions of many individuals to whom the editors extend their gratitude. First, we wish to thank the members of the committee whose involvement, participation, and interest ensured the timely and successful completion of the project. Second, we thank the workshop speakers, whose contributions cannot be overstated. The quality of their papers is a testament to their efforts. We are also grateful to the sponsors of this project, the National Science Foundation, Public Entity Risk Institute, and U.S. Nuclear Regulatory Commission. They provided support for project staff, administrative and editorial services, committee meetings, the workshop and follow-up meetings, and the compilation and publication of this report. Finally, we extend our thanks to the NAE staff who helped in the day-to-day operations of the project and in assembling and publishing the report. Proctor Reid ensured that the project was conducted in accordance with NAE policies. Nathan Kahl coordinated the logistics of the workshop. Carol Arenberg edited the manuscript and oversaw publication of the report. Penny Gibbs and Vivienne Chin provided administrative support throughout the project. James Phimister Vicki Bier Howard Kunreuther Project Director Committee Co-chair Committee Co-chair

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Accident Precursor Analysis and Management: Reducing Technological Risk Through Diligence Review Process This report has been reviewed by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council Report Review Committee. The purpose of this independent review was to provide candid, critical comments to assist NAE in making the published report as sound as possible and to ensure that the report meets institutional standards of objectivity, evidence, and responsiveness to the study charge. The review comments and the draft manuscript remain confidential to protect the integrity of the deliberative process. The review of this report was overseen by NAE member Harold Forsen, appointed by the NAE Executive Office. Dr. Forsen was responsible for ensuring that the independent review was carried out in accordance with institutional procedures and that all review comments were carefully considered. The reviewers were: Robert Coovert, Nuclear Operations, Exelon Generation Company; Elisabeth Drake, Professor Emeritus, Massachusetts Institute of Technology; William R. Freudenburg, Professor of Environmental Studies, University of California at Santa Barbara; Deborah Grubbe, Corporate Director, Safety and Health, DuPont Company; Granger Morgan, Lord Chair Professor in Engineering, Professor and Department Head, Engineering and Public Policy, Carnegie Mellon University; D. Warner North, President, NorthWorks, Inc.; and Edwin Zebroski, Independent Consultant. Responsibility for the final content of the report rests entirely with the authoring committee and the institution.

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Accident Precursor Analysis and Management: Reducing Technological Risk Through Diligence Contents SECTION I:   COMMITTEE SUMMARY REPORT          The Accident Precursors Project: Overview and Recommendations   3 SECTION II:   KEYNOTE SPEAKERS          The Opportunity of Precursors James P. Bagian   37      On Signals, Response, and Risk Mitigation: A Probabilistic Approach to the Detection and Analysis of Precursors Elisabeth Paté-Cornell   45 SECTION III:   RISK ASSESSMENT          Understanding Accident Precursors Michal Tamuz   63      Defining and Analyzing Precursors William R. Corcoran   79      Nuclear Accident Precursor Assessment: The Accident Sequence Precursor Program Martin B. Sattison   89

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Accident Precursor Analysis and Management: Reducing Technological Risk Through Diligence SECTION IV:   RISK MANAGEMENT          Inherently Safer Design Dennis C. Hendershot   103      Checking for Biases in Incident Reporting Tjerk van der Schaaf and Lisette Kanse   119      Knowledge Management in High-Hazard Industries: Accident Precursors as Practice John S. Carroll   127 SECTION V:   LINKING RISK ASSESSMENT AND RISK MANAGEMENT          Cross-Industry Applications of a Confidential Reporting Model Linda J. Connell   139      Stuck on a Plateau: A Common Problem Christopher A. Hart   147      Ensuring Robust Military Operations and Combating Terrorism Using Accident Precursor Concepts Yacov Y. Haimes   155     APPENDIXES         A Letters to the Committee   177      Notes toward a Theory of Accident Precursors and Catastrophic System Failure Robert A. Frosch   177      Corporate Cultures as Precursors to Accidents Ron Westrum   182     B Workshop Agenda   187     C Workshop Participants   191     D A Note on Definitions   197     E Biographies of Authors   199     F Biographies of Committee Members   205