Learning from accidents: Nontechnical skills deficiency in the European process industry

Safety‐critical industries have long been subjected to extensive research and development to enhance operator performance to improve their efficiency. From a human factors perspective, much of the work in process industries is related to either enhancing technical training of operators or related to improving the physical ergonomics of hazardous workplaces. The importance of Nontechnical Skills (NTS) in the process industries have traditionally been less emphasized, while other domains (e.g., aviation, healthcare) have led the development of investigating and improving NTS for the sharp‐end operators. This study aims to investigate the association of NTS deficiencies to the major accidents from the past 5 years in the process industries within the European Union by analyzing the accident reports from The Major Accident Reporting System (MARS) database. The accident analysis results reveal potential NTS deficiencies in 27% (17 out of 64) of the cases involving the lack of situational awareness, decision making, problem‐solving, communication, leadership, and time management issues. Based on the results of the analysis, a few implications, as well as future research directions, are proposed, which could facilitate the stakeholders in addressing NTS deficiencies of European process industry operators.


| INTRODUCTION
Process industries are complex sociotechnical systems that are engaged in the extraction, transportation, and processing of raw materials to manufacture semi-finished or high-quality end products by means of physical, mechanical, and/or chemical processes. 1 The evolution of the process industry throughout the last century has brought about transformational changes in technology usage, in the role of human operators, and the nature of their coexistence in complex sociotechnical workplaces. 2 As the role of humans changed towards more supervisory positions with increasingly automated processes and systems, the underlying organization and the human-machine interaction in those work environments also changed. 3 The appropriate competency along with adaptive capabilities of human operators are highlighted in the literature as necessary factors for efficient operations in complex industrial environments. 4 Therefore, the lack of appropriate skills coupled with the increasing technological complexity in process industries can result in failures leading to accidents. 5 In addition, issues ranging from technical deficiencies to organizational management and human factors items are reportedly found to have links with industrial accidents. 6 The importance of Nontechnical Skills (NTS) in addition to the technical skills for safe and efficient operations have been emphasized in different domains (e.g., aviation, energy, maritime, and healthcare). [7][8][9][10] Consequently, the scope and requirements for ensuring safety in "process industries" have evolved further, taking into account differing issues related to NTS in complex sociotechnical systems. 2,11,12 Earlier studies highlighted the lack of appropriate skills of the operators involved, such as communication, leadership, situational awareness, and decision-making skills, as contributing factors that could lead to differing failures in an industrial context. Therefore, different types of existing, as well as emerging NTS deficiencies that are prevalent in contemporary accidents, could be highlighted by analyzing recent accident reports from the European process industry.
Risk mitigation by analyzing failure events, for example, accidents, is a common practice in all domains and has taken numerous methodic approaches in the literature. Demin gs circle (1950), Reason's (1990) swiss cheese model and Kjellén's (2000) safety information model are some of the most prominently used models in industrial contexts. [13][14][15] Lessons learned from these events help understand the underlying contributing factors while mitigating future risks if addressed and acted upon. European process industries are no different from this type of risk mitigation approach.
The "Seveso Directive -Technological Disaster Risk Reduction" administered by the European Commission mandates easy access to accident data for taking precautions both in legislative and industrial practices. 16 The European database of the Major Accident Reporting System (MARS) serves as one of the repositories where industrial incidents and accidents that have occurred within the European Union (EU) are reported. This database aims to serve as a transparent and objective source of lessons learned information and a detailed account of the reported accidents. 17 The aim of this study is to investigate the contemporary major accidents occurring in the European process industry as reported in the MARS database and elicit their potential linkage to NTS deficiencies from the accident reports. Based on the findings of this study, general implications related to training, strategy, industrial practice, and objective reporting are proposed, which could potentially enhance nontechnical skills (NTS) of the operators, as well as industrial safety in general.

| NTS IN PROCESS INDUSTRY
The cognitive and social skills required for efficient and safe operations are termed as NTS in academic literature. 12 Originating from the aviation industry in the late 1970s, the term nontechnical skills (NTS) has been promulgated in other domains (e.g., healthcare, maritime, process, and nuclear industries) over the years. Consequently, the NTS training method, that is, Crew Resource Management (CRM) training, initially formalized for aviation pilots, has been adopted in However, the necessity for appropriate NTS training methodologies suited for process industries has been underlined in recent literature. 19,20 The crucial NTS required for process engineers to ensure efficient operations in both traditional (i.e., where work methods and processes are individualized) and in team-based work environments are highlighted by Downing. 21 He suggested that NTS, such as listening, decision making, verbal communication, problem-solving, and leadership were required for a team-based work environment, whereas listening, decision making, problem-solving, time management, and verbal communication were crucial for a traditional work environment. 21 A study by Crichton and Flin highlighted the necessity of situational awareness, teamwork, leadership, and stress management for T A B L E 1 Definition of different nontechnical skills (NTS) categories 26

NTS Definition
Situational Awareness Forecast and find solutions: situational awareness refers to being aware of the surroundings, and involves the capability of evaluating critical environmental cues, processing vital safety information, forecasting near-future occurrences, and finding a way out from the emerging risks 27 Decision Making Considering optionsgenerating alternative possibilities or courses of action. Assessing hazards and weighing up threats and benefits of potential actions 26 Problem Solving Seeking appropriate answers-the ability to integrate information from several different sources in order to improve organizational performance through the integration of multiple platforms, functions, and technologies 28

Communication
Establishing a shared understanding and ensuringensuring that the team has the necessary information to carry out the resolution, understand it, and that an acceptable shared "big picture" of the case is held by team members 26 Leadership Coping with pressureretaining a calm demeanor when under pressure and demonstrating to the team that the situation is under control. Adopting a suitably forceful manner, if appropriate, without undermining the role of other team members 26 Time management Monitoring and controlling timeself-management with regard to the performance of multiple tasks within a certain time period 29 Fatigue management Monitoring and controlling habitmanagement of a complex biological phenomenon that occurs as a function of active working time, time-of-day, workload, health condition, and off-duty lifestyle 30 nuclear emergency response teams in addition to the NTS identified by Downing. 22 Marco et al. proposed a four-factor model comprising situational awareness, decision-making, communication, and fatigue that are identified as the most important NTS for ensuring safety in chemical industries. 23 The variability of NTS requirements based on differing contexts is observed in previous studies. 24,25 The relevant NTS fit for the process industry context for day-to-day operations is compiled here based on the findings of previous studies as situational awareness, decision making, problem-solving, communication, leadership, time management, and fatigue. The most appropriate definitions of the above-identified NTS are consolidated in Table 1.

| METHODS
The accidents reported in the MARS database from all process industry types within the EU are stratified into three categories: "major accident," "near miss" and "other event." However, only the recent accidents resulting in human injury or damage to the property and the environment, that is, the major accidents, were taken into account for this analysis since this study is directed to understand the existing, as well as emerging NTS deficiencies related to those accidents. Therefore, the latest dataset from the past 5 years (January 2017 to August 2021) was extracted from and filtered based on their availability of full accident reports in the database. Only the MARS database is used as a source of the accident reports since it is mandated by the European Commission for all European process industries to report their incidents in the database under the Seveso directive 2012/18/EU. 16 The reports are made online, and therefore, it is also referred to as eMARS database. Two focused-group workshops with two human factor experts were operationalized to analyze the accident reports where the generated codes were noted on paper. A combination of inductive and deductive approaches was taken in order to confirm the association of NTS deficiencies with the reported accidents. The content analysis followed

| RESULTS
The initial screening of accidents extracted from the MARS database, which occurred in the process industries in Europe over the past 5 years, elicited 103 events in total (see Figure 1).
Although there are 103 accidents reported from the past 5 years, only 64 had written accident reports available (full or partial). Based on the established criteria for analysis, it was revealed that 17 of those accidents (27% of total 64 written reports) had links to NTS deficiency of operators. The analysis also highlighted that each NTS deficiency has an association with multiple accidents (see Table 2). Situational awareness, decision making, problem-solving, communica- therefore, other types of identified skill deficiencies could also be alleviated by adopting appropriate strategies. The implications on account of the industry, as well as the future research direction section, include a few of the potential directions that can be adopted in this regard.
This study also identifies the need for an effective reporting system with an explicit focus on NTS deficiencies that may result in accidents.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available in The Major Accident Reporting System (MARS) of Europe at https://emars. jrc.ec.europa.eu/en/emars/content