4. Conclusion
We provided an understanding, based upon empirical study, of how actions and decisions at the higher organizational and managerial levels in oil and gas industry result in errors and violations. The results showed causal paths that relate errors and violations at operation level with inadequacies at both the immediately adjacent and higher levels. This study drew a clear picture that supports Reason’s (1990) model of active failures resulting from latent conditions in the organization. After the comparison with the frequency-based method, the results showed that the SEM-ANP method can reduce the biases of experts and provide more reasonable and comprehensive assessment. Observations by the frequency-based method from accident reports were also analyzed, and the specific and feasible recommendations are given.
The results showed that “organizational process”, “inadequate supervisions”, “supervision violations”, “personal readiness”, “errors” and “violations” are the factors which have more important influences on safety work. And investments in “organizational process”, “inadequate supervisions” and “supervision violations” can be more efficient. Especially, the improvement of “organizational process” can reduce the “inadequate supervisions” and “supervision violations”. The managements in “inadequate supervisions” and “supervision violations” can improve the situations of “personal readiness”, “technological environment” and “crew resource management”, and therefore can reduce the occasions of “errors” and “violations”. Interventions at “unsafe acts of operators” level and “preconditions for unsafe acts” level would only have limited effects on improving the overall safety. After all, improving the factors in the lower levels depends on the factors in the higher levels. As the root, factors in the higher levels, such as “organizational process” and “inadequate supervisions”, play an important role. Therefore, organizational can strengthen the governance of factors in the higher levels based on holistic considerations.