Safetyrelated incidents TIA Reporting System Michael Plagge Helen

Safety-related incidents – TIA Reporting System Michael Plagge, Helen Boyer and Nicolas Eke OHS Engineers www. europeanspallationsource. se

Why encourage reporting? • To obtain and update knowledge on present and new hazards and related risks • To identify causes and mitigate those ALARP • To ensure that people involved receive the necessary support “Take the opportunity to treat every near miss as it would have been an accident and learn from it as much as you can!” Frank Kornegay, former Safety & Health Director at the Spallation Neutron Source SNS during ESHAC #9 2

What is TIA? TIA is derived from Swedish: ” Teknisk informationssystem om Arbetsmiljö”. At ESS Safety & Security we will refer to it as “Incident reporting system”, keeping the abbreviation “TIA”. 3

What is a safety-related incident? “Any unintended event, including operating errors, equipment failures, initiating events, accident precursors, near misses or other mishaps, or unauthorized act, malicious or non- malicious, the consequences or potential consequences of which are not negligible from the point of view of protection and safety of personnel. ” IAEA Safety Glossary, 2016 Revision, modified More definitions in ESS-0287688 ESS Procedure for Incident Reporting 4

Who shall report? Open to anybody at all ESS workplaces! https: //openclipart. org/detail/22519/crowd, modified 5

Where do I report? • • TIA is accessible with a single link (also to be found on Confluence). No login or password is required, accessible from anywhere. Link 6

How to report? Link 7

How to report on human behaviour? For any human behaviour deemed unsafe: • Stop and talk to the person • Ask questions about their work task and how they consider their work risks adequately controlled • Discuss the specific unsafe behaviour and reach an agreement about the action to be taken Following this safety dialogue report an incident. A. A. Johannesson , J. Segerlund et al. , SEC Toolbox 15 T_61, 2018 -04 -13 8

What happens after a reporting? Observe incident Deal with incident Report incident Communicate incident Investigate incident Input Assign actions Follow up on actions Close out investigation Lessons learned Output ESS-0287688 ESS Procedure for Incident Reporting 9

Data for 2018 -1 -1 to 2018 -10 -24 ty n io ce 2 at rv se Ob en rg 0 Sa fe ive ity cu r Se t 9 he rd ty / en m 45 Ot er op on s es illn 2 Pr vir En te d t t en en id ga cc la re k- or W in ut cid Ac n iss ar m Ne at io rv se ob Number of incidents reported [-] 50 45 40 35 30 25 20 15 10 5 0 Co m m sk Ri Regular feedback and lessons learned SSM reportings: 3 Ratio: 2. 6 17 11 1 5 10

Where do I get support? System owner: ESH Division Responsible staff: Michael Plagge Backup: Helen Boyer Nicolas Eke Support documents available for • Administrators • Incident managers • Line managers • Reporting users • Safety delegates Unknown ESS premises, April 2018, taken by the 1 st author 11

ohs@esss. se