Pattern recognition for process safety

FractalSafe

Ask the same five questions about one critical control at four scales: the task, the team, the site and the organization. Then look at what repeats. When the same weakness shows up at every scale, you have found the pattern that will decide the next incident.

A fractal is a shape that looks the same however far you zoom in or out. I use the word as an analogy. In the fatality files I have read, the gap in the task (a step skipped under time pressure) was usually a smaller copy of the gap in the organization (a budget decision made under the same pressure). Nobody saw it because each scale was reviewed by different people with different forms. This tool puts all four scales on one page.

What this is. A structured review aid. It organizes your own answers and counts where they repeat. It does not know your plant, it does not predict incidents, and it is not a substitute for a process hazard analysis, a bow-tie or a competent engineer.

  1. 1 · Name itPick one critical control or system to review.
  2. 2 · Fill the gridFive questions at each of four scales. Tag each answer.
  3. 3 · See the fractalThe tool highlights tags that repeat across scales.
  4. 4 · ActPatterns map to CRM™ pillars and the frameworks to deploy.

1. What are we reviewing?

One thing, named precisely. "Hot work permit on the crude unit" works. "Safety" does not.
Who is reviewing, when, and what prompted it.
Load a worked example

The examples are anonymized and illustrative, assembled from patterns I have seen across many sites. None describes a single real company or event.

2. The grid: five questions, four scales

Answer in a sentence or two, then pick the tag that best describes the type of answer. The tags are what the tool compares, so choose the one that is most true, and leave a cell blank if you do not know (the summary treats blanks as information too).

    0 of 20 cells tagged
    Saves on this device as you type.

    Your data

    The grid is stored in this browser only, under one key, and nothing is sent anywhere. Printing is the export.

    A neuroscience-informed safety system built from more than thirty years in high-hazard work and more than fifty fatality investigations. All frameworks proprietary to Safety Sense Inc.

    FractalSafe is a structured review aid built on the Cognitive Reliability Model™ (CRM™). It organizes and counts your own answers. It is not a predictive model and not a replacement for formal process hazard analysis.

    References and further reading

    • Rasmussen J. Risk management in a dynamic society: a modelling problem. Safety Science. 1997;27(2-3):183-213 (drift toward the boundary of acceptable performance). https://doi.org/10.1016/S0925-7535(97)00052-0
    • Dekker S. Drift into Failure: From Hunting Broken Components to Understanding Complex Systems. Farnham: Ashgate; 2011. ISBN 978-1-4094-2221-1.
    • Reason J. Managing the Risks of Organizational Accidents. Aldershot: Ashgate; 1997. ISBN 978-1-84014-105-4.
    • International Council on Mining and Metals. Critical Control Management Implementation Guide. London: ICMM; 2015. icmm.com
    • Mandelbrot BB. The Fractal Geometry of Nature. New York: W. H. Freeman; 1982 (the source of the analogy; the tool makes no mathematical claim).