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Experience feedback
 

Experience feedback

The vigilance and anticipation system involves experience feedback, i.e. the collection, analysis and sharing of information and lessons learned from accidents or incidents so that the necessary improvements can be implemented: technical measures, organisational aspects. Experience feedback is first and foremost the responsibility of the operator.

For classified installations, the “organisational and human factor” is determinant in 90% of fatal accidents with known or suspected causes. Works on installations constitute the circumstances or the actual causes of 30% of these accidents.

This implies increased presence in the field in terms of management, verification, audit and inspection. The decrease in the number of accidents is at stake.

The Office of Risk and Industrial Pollution Analysis (BARPI) provides those involved in risk prevention with information and lessons learned from industrial and technological accidents 2Feedback principle2 The idea is to take advantage of negative and positive observations to improve action. This process, which involves the implementation of an appropriate organisation between the different players involved (operator, management, network operators, service providers, subcontractors etc.) involves different phases:

  • identify, characterise, analyse and record the positive or negative elements available to derive useful lessons
  • develop a strategy of action and share the useable information with all those involved
  • follow-up the actual application of this strategy; detect variances, make the necessary corrections and adaptations
  • compile experience feedback in good practice documents and share them with other players likely to be confronted with comparable situations

Historically speaking, two types of experience feedback have emerged:

  • the first one subsequent to the accident
  • the second one implemented for the detection of simple incidents, without waiting for the accident to happen. 2Accident feedback2 Accident feedback, although by nature a belated process, enables the company affected by the accident to:
  • raise the awareness of numerous people involved in prevention, in light of the significance of the consequences,
  • improve mitigation, intervention or consequence limitation measures,
  • realise, an often difficult and sudden process, the limitations of a preventative approach. This type of feedback also includes a significant aspect in terms of communication and relationship with the general public. 2Incident feedback2 This second type of feedback is based on anticipation. As accidents are often the result of an accumulation of basic failures, the objective is to resolve most of them as much as possible before their combination leads to the critical path of an accident. This incident feedback management policy is specified for the operators of upper tier Seveso sites by article 7 and appendix III-6° of the ministerial order of 10 May 2000.

It is supported by a “continuous safety improvement process” consisting of:

  • detecting failures and anomalies at source,
  • recording them,
  • analysing them,
  • developing technical and organisational solutions,
  • implementing them,
  • and following up their application over time.

This process, based on the active involvement of the players (network operators, managers, subcontractors etc.) within exchange or working groups, makes it possible to:

  • avoid falling into a routine and “normalising deviations”,
  • progressively develop a follow-up and alert function,
  • complement theoretical studies by field data and vice versa.

The anomaly detected and errors identified are the foundation of experience feedback. This identification should not be hindered; on the contrary, employees should be encouraged to pass on the corresponding information. The success of this approach requires a type of social relationship promoting the vigilance and participation of the employees concerned in the development of remedies. The efficiency of this process depends on the strong involvement of management and each level of the company as well as an appropriate organisation.

Examples of major accidents in industrial history which helped improve risk prevention:

1794 – Grenelle powder factory (France, 75)

1966 – Feyzin (France, 69)

1984 – Mexico City (Mexico)

1986 - Basel (Switzerland)

1987 – Edouard Herriot Port, Lyon (France, 69)

1992 – La Mède (France, 13)

1997 – Blaye (France, 33)

2001 – Toulouse (France, 31)

Legislation

Ministerial order of 10 May 2000 relative to the prevention of major accidents involving hazardous substances or preparations present in certain categories of classified installations for environmental protection

Useful sites

ARIA: List of technological and industrial accidents
BADORIS: Technical safety barriers implemented in classified installations
PRIM.NET: prevention of major risks 2Contact2 INERIS
MEDDTL: Ministry for Ecology, Sustainable Development, Transport and Housing
DREAL: Regional Directorate for Industry, Research and the Environment