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Using accident precursor events for supporting a dynamic risk analysis at lean
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Conference Paper · September 2015

DOI: 10.1201/b19094-428

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 Safety and Reliability of Complex Engineered Systems – Podofillini et al. (Eds)
© 2015 Taylor & Francis Group, London, ISBN 978-1-138-02879-1

Using accident precursor events for supporting a dynamic

risk analysis at lean workplace

Serena Andriulo & Maria Grazia Gnoni

University of Salento, Lecce, Italy

Vincenzo Duraccio
University Niccolò Cusano, Rome, Italy

ABSTRACT:  Lean management is a performance-based strategy to reduce costs, achieve higher quality
levels and increase competitive advantage of companies. A synergy may be found between the accident
precursors analysis, required by the safety management systems, and the knowledge sharing principle,
typical of lean approaches. A structured framework for supporting a dynamic interaction between the
actual condition of the workplace and risk analysis is proposed. The framework will integrate knowledge
derived from leading indicators (e.g. accident precursor events, near misses) with company risk analysis
approaches applied to evaluate occupational risks. This approach is in line with lean safety strategies
where feedback loops derived from the operational field are essential to re-define company strategies
towards occupational safety. The framework will be quantitatively tested in a real case study regarding
a manufacturing firm which widely applies lean management. Collected data about accident precursors
will be analyzed according to results derived from the company risk analysis document aiming to evaluate
a more dynamic process for evaluating risks at workplace. The proposed framework will aims to “trans-
late” practices applied in high risk level sectors (e.g. the process industry) according to the most wide-
spread strategy applied in the manufacturing sector (i.e. the lean management). The general framework
proposed will support companies to apply dynamic risk analysis with a reduced effort required by the
organization.

1  introduction enhance safety level of a firm have to be pulled

Lean management is a performance-based strat-
egy to reduce costs, achieve higher quality levels
and increase competitive advantage of companies.
Leadership, team-based culture, communication
and continuous improvement are the pillars. Lean
approaches were firstly applied in the automotive
sector, and now they are wide spreading in many
industries worldwide. One effective strategy is the
Lean Thinking or Lean Manufacturing concept
(Womack and Jones, 1990): in brief, the aim is to
reduce “waste” in all processes which are involved
for supplying a product or a service. Although
a huge number of studies have been focused on
lean management in manufacturing processes, few
recent works are facing with the integration of
safety issues in lean thinking approaches (Brown
and O’rourke, 2007; Taubitz, 2010; Hafey, 2011).
This strategy determines a new way to design
and control manufacturing processes and conse-
quently health and safety issues. Safety manage-
ment in lean manufacturing environments have to
change their traditional prospective: activities to
by actual system requirement rather than pushed
uniformly onto workers and procedures (Rozen-
feld et al., 2010; Longoni et al., 2013). According
to a safety management point of view, lean safety
strategy introduces new issues problems mainly
due to stressing objectives and the multitasking;
on the other hand, it also offers interesting oppor-
tunities, related to the workers’ participation (Bra-
gatto et al., 2014).
Feedback loops derived from the operational
field become essential to re-define company strat-
egies towards occupational safety management
(Andriulo, and Gnoni, 2014). Learning from
leading indicators (e.g. near miss) could heav-
ily contribute to increase the effectiveness of
the company safety management system (Payne
et al., 2010; Drupsteen and Wybo, 2015; Leveson,
2015).
The paper proposes a quantitative cross analysis
between data collected from a Near Miss Manage-
ment (NMM) system and assessments of risk level
defined in the Risk Analysis Document (RAD).
Data derived from a real case study regarding a

3253
manufacturing firm which widely applies lean
management are discussed. Collected data about
accident precursors will be analyzed according to
results derived from the company RAD aiming to
evaluate a more dynamic process for assessing risks
at workplace.
2  THE CASE STUDY: A LEAN
MANUFACTURING COMPANY
2.1  The production system in analysis
The company in analysis has developed its own
model for applying lean principles, the so called
Bosch Production System (BPS). Main principles
constituting the BPS are depicted in Figure 1. In
brief, the BPS aims to achieve customer satisfac-
tion trough high quality, shorter delivery times
and lower costs. Furthermore, all these targets
have to be reached by increasing the satisfac-
tion and motivation of all workers, standardizing
processes and by involving—in a “pull” logic ver-
sus traditional “push” process—high involvement
of all employments in continuous improvement
processes.
Since from 2008, the firm has started a project
for applying continuous improvement philosophy
in all sectors from production planning to environ-
ment and safety management.
The Continuous Improvement Process (CIP)
within an organization offers the opportunity
for all firm activities (e.g. production, logistics,
administration) to improve day by day as syn-
ergies derived from all firm functions allows to
leverage knowledge within the firm. Several
tools and “knowledge sources” belonging to CIP
have been analysed aiming to highlight most
effective areas of intervention for introducing a
NMS.
Based on the CIP process, the aim of this work
is to define how knowledge provided by the com-
pany Near Miss Management system could sup-
port a more dynamic risk analysis. The prosed
Figure 1.  Main pillars of the BPS.
3254
analysis will be based on the well know concept
Learning From Experience which traditionally, in
occupational safety management, refers to apply-
ing root cause analyses of both accidents and inju-
ries occurred at workplace (Pasman, 2009; Dechy
et al., 2012).
By focusing on the occupational safety manage-
ment system, the company risk assessment model is
based on risk matrix: risks for each task, which can
be performed in one or more departments of the
plant, have been quantitatively assessed through
a risk matrix based on occurrence and magnitude
scales.
The company has been divided in 10 organiza-
tional areas which are the most critical according
to risk level. A brief description of each area is
reported as follows:
• DEP1: this is a staff department as it supports
the application of the BPS in all plant areas from
production to administrative ones;
• DEP2: this is a staff department which supports
company management for external and internal
communication process using different media
and tools;
• DEP3: this is the company ICT department;
• DEP4: it carries out logistic and warehouse
activities supporting all production areas;
• DEP5: it’s responsible for producing and assem-
bly products with low demand (i.e. brakes for the
automotive market);
• DEP6: it carries out the production and the
assembly of components for high demand prod-
ucts ( i.e. diesel pumps);
• DEP7: it’s responsible for quality control of
products and processes;
• DEP8: it carries out facility management in all
firm areas and it’s responsible for the manage-
ment and maintenance of the facilities within
the plant;
• DEP9: it’s responsible for the manufacturing
and the assembly of the components of the gear
pump;
• DEP10: it’s responsible of all R&D activities for
the improvement of the products.
Risk types evaluated in the company RAD are
20: they have been reclassified by using a stand-
ardized methodology proposed by ESAW (ESAW,
2012). A full description is in Table 1.
The company has proposed a six level evaluation
scale for the assessment of the risk gravity level: it
is proposed in Table 2.
Next, risks previously outlined have been
assessed for all departments based on the magni-
tude scale: results are proposed in Table 3.
Data outlined DEP9 as the most critical area at
the workplace; DEP1, 2 and 3 are the less critical
ones.
Table 1.  Risk categories evaluated in the company.

Risks Description

R1 Risks related to the workplace: these are all risks related to the work environment but not directly connected
to the specific task performed by workers
R2 Risks related to the microclimate and lighting: these are all risks related to environmental condition of the
workplace
R3 Risk related to work in confined spaces: these are all risks related to workplace characterized by limited
accesses
R4 Risk related to work at height: these risks are related to all activities performed at an altitude higher than the
stable surface
R5 Fire risk: this are mainly due to the presence of combustible and/or flammable materials, or with presence of
ignition sources
R6 Risks to the presence of explosive atmospheres: these are all risks related to work environments (indoor or
outdoor) where there are gases, flammable fumes and liquids, or combustible dusts
R7 Seismic risk and natural disasters: these are all risks related to physical phenomena and natural elements
R8 Risks associated with the use of machinery and work equipment: these are risks due to the interaction
between worker’s tasks and machinery
R9 Risks associated with installation and electrical equipment: these involves the use of electrical systems, equip-
ment and tools for performing tasks
R10 Risk related to pressure equipment: these are connected to the use and/or the presence of pressure equipment
R11 Risk related to transportation: these are all risks related to the use of handling systems
R12 Risks related to exposure to chemicals: these are all risks related to the use of dangerous chemical substances
R13 Risks related to exposure to carcinogens and mutagens: these are all risks related to the presence of carcino-
gens or mutagens in the workplace
R14 Risks related to exposure to asbestos: these are all risk related to the presence of asbestos in plant areas
R15 Work-related stress: these depend on tasks that could cause physical or mental stress to the worker
R16 Risks related to exposure to noise: these are all risks related to tasks which involve noisy equipment and tools
R17 Risks from vibration: these are all risks related to the use of powered machinery, equipment and tools caus-
ing strong vibration
R18 Risks from artificial optical radiation: these are all risks related to the use of equipment or machinery that
cause artificial optical radiation
R19 Manual handling of loads: these are all risks related to activities that require manual handling of loads
R20 Use of video terminals: these are all risks related to the use of video terminals for a long time

Table  2.  Proposed qualitative scale for 3  A cross analysis based on

assessing magnitude of risk categories. leading indictors and risk
levels
Magnitude level Description
The focus of this analysis is to outline the con-
NA (1) Not applicable
tribution of leading indicators (i.e. accident pre-
N (2) Null
cursors) to support CIP process in company risk
NE (3) Negligible
L (4) Low
assessment: in detail, data collected from the Near
M (5) Medium
Miss Management System will be used to improve
H (6) High the risk assessment phase.
Three main steps will be carried out:
Step 1: at first, a cross analysis for verifying if all
Table 3.  Results of the company risk assessment ­process types of risk evaluated in the RAD will be car-
for each analysed area. ried out;
Step 2: following, the analysis will focus on verify-
ing if the assessment of each type of risk in each
area of the plant reflects analysis developed in
the RAD in terms of presence and magnitude;
Step 3: it consists of analysing critical points out-
lined by previous analyses, to identify future
actions for CIP of the company risk assessment
process.

3255
 The first step of the study has been to analyse
the near miss reporting data for classifying them
according to risk categories outlined in the previ-
ous section, i.e. applied in the RAD development.
Data have been collected from June 2014 to Febru-
ary 201: the total number of events is equal to 119,
where 106 events have been classified as Unsafe
Situation, 10 as Near Miss and 3 as Unsafe as
depicted in Figure 2.
The ESAW methodology (ESAW, 2012) have
been used, in order to perform a properly classi-
fication of the precursor events reported accord-
ing to the risk categories explained above. Results
outlined a greater presence of four types of risk:
R8 (risks associated with the use of machinery and
work equipment) with slightly more than 50%, R1
(risks related to the workplace) with about 17%, R9
(risks associated with plants and electrical equip-
ment) with more than 8% and R20 (risk associated
to manual handling of loads) with about 7%.
Furthermore, collected data about accident pre-
cursors have been grouped for each department:
results are in Figure 3. by analysing data based on
each department, the most critical working area
is the DEP6, with more than 60% of reports with
R8 as risk type, about 9% of reports with R1, 8%
of reports with R20 and about 6% of reports with
Figure 2.  Collected data from the company Near Miss
Management system.
Figure 3.  Number of events collected for each company
department and for each risk category.
3256
R9; the same in DEP9, with 66% of reports with
R8 as risk type, 16% of reports with R1, 6% of
reports with R20 and 3% with R9; In DEP4 both
of R8 and R20 have 33% of classified reports, and
both of R1 and R9 have 17% of classified reports;
DEP7 has 30% of reports with R8 as risk type,
30% with R9, and both of R20 and R1 with 10%
of classified reports. The high presence of these
4 risk categories, in particular the R8, in these
departments could be due to the types of tasks
carried out in this area: DEP6 and DEP9 are the
production departments where the machining and
the assembly of the work-pieces are carried out;
for DEP4, the strong presence of R20 and R8 is
deductible as it’s the department that performs all
the logistic tasks and the material handling; also
for DEP7 these risks are associable as it’s the qual-
ity department, where all the laboratory checks are
performed for considering products suitable by
using machinery and powered equipment.
This first analysis has underlined an interest-
ing result: some reports didn’t fall in any of risk
categories evaluated in the RAD; so these reports
have been classified according to their kind, and
this has allowed to define three new risk categories
that could be inserted in the risk assessment phase.
These three new risk categories are:
1. Risk connected to wrong work procedures;
2. Risk related to human factor;
3. Risk related to facilities.
The second step of the study has been to verify
for each department if the risks categories out-
lined by the NMM system have been outlined by
the RAD Results are in Table  4 information col-
lected by the NMM system are compared with
ones derived from the RAD.
This analysis has highlighted in general that the
presence of risk categories identified for precursor
events reported have been already evaluated in the
risk assessment phase. One anomaly could be out-
lined for DEP9, i.e. the absence in the risk assess-
ment of DEP9 of the R8 as risk type.
The last phase of the study has been to verify
if the evaluation of risk categories in the risk
Table  4.  Comparison between risks outlined by data
collected from the NMM system and RAD.
a­ ssessment phase has been done effectively in terms Table  6.  Comparison between risk levels evaluated in
of magnitude, verifying the presence of poten- RAD and information collected from the NMM system.
tial criticalities that can be underline continuous
improvement points, to refine upon the risk assess-
ment analysis. This has been performed by com-
paring the magnitude of each risk type, assigned in
the risk assessment of each department, with the
level of criticality of each risk categories identi-
fied in the precursors reported in each department.
At first, the total number of occurrence have been
evaluated for each risk category in each depart-
ment; results are reported in Table 5.
A level of criticality has been assigned to each
risk category, by calculating the relative occurrence
(expressed in percentage) about how each risk type
is present in each department. The level of criti-
cality have been assigned based on the following
scale:
• If (risk type presence ≤ 1%), the level is defined
have to be improved as there’s yet something not
as NOT CRITICAL (1);
well monitored.
• If (1%  <  risk type presence  ≤  20%), the level is
DEP5, that is the production departments of
defined as NEGLIGIBLE CRITICALITY(2);
brakes, has two criticalities, respectively for R1 and
• If (20% < risk type presence ≤ 40%), the level is
for R8. These two risk types have been identified in
defined as LOW CRITICAL (3);
the risk assessment with a low level of magnitude,
• If (40%  <  risk type presence  ≤  60%), the level
so there are already several procedures and safety
is defined as CRITICAL (4).
systems that restrain these risks; NMMS provides
• If (60% < risk type presence ≤ 80%), the level is
more suggestions for not underestimate these two
defined as VERY CRITICAL (5);
risk categories.
• If (80% < risk type presence ≤ 100%), the level is
DEP6 and DEP9 present a very critical point
defined as HIGHLY CRITICAL (6).
for R8: this risk type is obviously considered in
A comparison between data collected by the the risk assessment for the production depart-
NMS and RAD have been developed; data are ments, but the NMMS underlines an higher level
reported in Table 6. of criticality respect to the magnitude considered
These last phase of the analysis has outlined that in the risk assessment; These information are a
in general the magnitude has been assigned effec- good point to adjust and improve the safety pro-
tively, and the several risk types are kept well under cedures for DEP6; for DEP9 the non presence of
control. Some critical point have been identified. the R8 evaluation could be due to the fact that is
DEP1, DEP2, DEP3 have respectively for R9, R1 a new department that is on-going from about 8
and R2 an high criticality: they are staff depart- months, so the qualitative risk assessment analy-
ments, so is difficult to have high risk; the pres- sis sure needs revisions; the NMMS information
ence of reports in these departments outlines that could be considered a good source for starting the
some procedures that manage that risks (in terms risk assessment improvements.
of workplace, illumination system and equipment) Finally, DEP10 has a very critical point for R1;
it is a staff department so this report has high-
lighted that there’s an underestimation of risks
Table 5.  Distribution of events based on risk category related to the workplace; this could be an informa-
for each department. tion for increasing the monitoring and the safety
procedures that can control this risk type.

4  CONCLUSIONS

The study have proposed a new way to use accident

precursor data as leading indicators for safety lev-
els at workplace.
Data derived from a real case study have pro-
vided the potentiality of the proposed approach

3257
for supporting in an effective way companies for
Continuous Improvement process. Further devel-
opment will be oriented in analysing based on a
more operative level the contribution of accident
precursors to each risk assessment evaluation.
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