The Study of Near Misses and the Knowledge Management in Mature Industries

ABSTRACT In mature industries, a terrific knowledge about safety is hidden in regulations, standard codes and good practices, as well as in proprietary procedures. The study of near misses may be used to rediscover and to revive this knowledge. Internal proprietary knowledge and external public domain knowledge have been discriminated. For the proprietary knowledge the right pieces of procedures are searched through a backward path along safety digital model, which is able to represent all the links between equipment and safety documents, within the safety management system. For the formal external knowledge, a semantic search was used. Safety matter has been organized in taxonomies used both to find the key words in the near miss report and to match them within the mess of public documents. KEYWORDS Near-Misses; Knowledge Reviving; Safety Management System, Safety Regulation 1. INTRODUCTION The understanding of accidents and near misses is essential for an efficient Safety Management System (SMS) in the process industry. The benefits of having a good program for reporting and analyzing any non conforming events have been widely demonstrated in many papers [3], [4], [12], [15], [16], [17], [20]. There are definitely much more near-misses, than severe accidents. Furthermore near misses are very easy to identify, to understand, to control. They are simpler to analyze and to resolve, than real accidents, where evidences could be obliterated.In this paper a wider meaning has been assumed for the word “near miss”, in order to include every non conforming event. In such a way it may be early detected any latent condition, which, given a slight shift in time or distance, might lead to an accident.Many enterprises have already systems for internal reporting dealing with all events, which deviate from normal conditions and which could have adverse effects on safety, health, environment or property. These systems are aimed to learn from experience, but often they are weak, as the learnt lessons seem to be forgotten, due the natural personnel turnover. Furthermore accident experience is useful just in the individual company, as knowledge sharing is very difficult to be implemented. In order to overcome these obstacles a new approach is proposed for mature industries.In these industries, the most knowledge underlying all the activities is assumed perfectly defined and formalized. Accidents very often happen not for lack of knowledge, but because it has been ignored, or forgotten, or distorted, or badly applied by the operators. It is supposed that, in certain type of industry, a structured and documented Safety Management System (SMS) is always present. In those establishments where European major accident legislation is enforced, the SMS is mandatory, in other cases it is strongly encouraged trough incentives. The SMS, according to the current regulations and standards, defines a framework, which organizes the safety issues along the lifecycle of the plant, including hazard identification and risk analysis, safety policy and management, operational procedures, emergency management and periodical safety audit.