2012ENMP0098

L’entreprise à l’épreuve des facteurs humain et
organisationnel : la pratique de l’analyse d’accident au

service de la sécurité à GrDF
Guillaume Desmorat
To cite this version:

Guillaume Desmorat. L’entreprise à l’épreuve des facteurs humain et organisationnel : la pratique
de l’analyse d’accident au service de la sécurité à GrDF. Gestion et management. Ecole Nationale
Supérieure des Mines de Paris, 2012. Français. �NNT : 2012ENMP0098�. �pastel-00871806�
HAL Id: pastel-00871806

https://pastel.archives-ouvertes.fr/pastel-00871806
Submitted on 10 Oct 2013
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1
1
Ecole doctorale n° 432 : Sciences et Métiers de l’Ingénieur
Doctorat ParisTech
THÈSE
pour obtenir le grade de docteur délivré par
l’École nationale supérieure des mines de Paris

Spécialité “Sciences et Génie des Activités à Risques ”
1
présentée et soutenue publiquement par
Guillaume DESMORAT
le 27 avril 2012
1 L’entreprise à l’épreuve des facteurs humain et organisationnel :

1
1 la pratique de l’analyse d’accident au service de la sécurité à GrDF
1
1
1
1 1
1
1
1 Directeur de thèse : Franck Guarnieri1
1
1
Jury T
M. Benoît JOURNE, Professeur à l’Université de Nantes Rapporteur
M. Gilbert de TERSSAC, Directeur de recherche au CNRS, UMR 5044 – CERTOP Rapporteur H
M. Christophe MARTIN, Directeur des études, ISP Fénelon Examinateur
M. Olivier RIEUX, Chargé de projet et d’expertise, Direction Technique et Industrielle, GrDF Examinateur
E
M. Franck GUARNIERI, Directeur, CRC, Mines Paris Tech Directeur de thèse
S
MINES ParisTech
Centre de Recherche sur les risques et les Crises
Rue Claude Daunesse, B.P. 207 E
06904 Sophia-Antipolis cedex
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Approche analytique Approche systémique
Isole : se concentre sur les éléments Relie : se concentre sur les interactions
entre les éléments
Considère la nature des interactions Considère les effets des interactions
S’appuie sur la précision des détails S’appuie sur la perception globale
Modifie une variable à la fois Modifie les groupes de variable
simultanément
Indépendante de la durée : les Intègre les notions de durée et de
phénomènes considérés sont réversibles réversibilité
Validation des faits par la preuve Validation des faits par comparaison du
expérimentale dans le cadre d’une théorie fonctionnement du modèle avec la réalité
Modèles précis et détaillés mais Modèle insuffisamment rigoureux pour servir
difficilement utilisables dans l’action de base aux connaissances mais utilisables
dans la décision de l’action
Approche efficace lorsque les interactions Approche efficace lorsque les interactions
sont linéaires et faibles sont non linéaires et fortes
Conduit à un enseignement par discipline Conduit à un enseignement pluridisciplinaire
Conduit à une action programmée dans Conduit à une action par objectifs
son détail
Connaissance des détails, buts mal Connaissance des buts, détails flous
définis
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Approche réactive Approche proactive (prédictive)
Modèle Modèle qualitatif de l’erreur humaine Modèle d’erreur quantitatif
Relations Déterminisme cause-effets Probabilisme cause-conséquence
entre les
évènements
Données de l’accident, connaissance Données de l’accident, connaissance
Base de
du domaine, modèles et taxonomie du domaine, modèles et taxonomie,
l’analyse
système réel, conception du système
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1
Niveau
Le plus visible Intermédiaire Le plus profond
Comportements Représentations
Modèle de Schein Croyances et valeurs
et artefacts sous-jacentes
Normes de
Artefacts comportement pouvant
Valeurs centrales,
(logo de la être déduites des
Modèle de pouvant ne pas être
marque) et comportements
Rousseau exprimées
comportements observés ; valeurs
consciemment
observables exprimées
consciemment
Niveau
manifesté :
Modèles de Deal artefacts Niveau central :
Niveau stratégique :
et Kennedy ; de symboliques, idéologies, valeurs,
croyances stratégiques
Lundberg histoires, rites, représentations.
comportements
normatifs
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761932ADB8617615318BA3AB1"1%D3A6D1161"B%61%88C761@A3456317A111
1
Mode brouillé Les actions sont choisies de façon aléatoire avec peu, voire
aucune, réflexion ou cognition
Mode opportuniste Le contexte n’est pas clairement compris ou le temps imparti est
trop limité. L’acteur agit en fonction des dispositifs les plus
évidents de l’interface homme-machine ou par ceux qu’il a
l’habitude d’utiliser.
Mode tactique L’action est guidée par un ensemble de procédures ou par des
instructions connues de l’opérateur. La réalisation de l’action n’est
cependant pas instinctive.
Mode stratégique Les actions sont choisies après une prise en compte réfléchie du
contexte dans son ensemble.
8>$6)111 6817B))D6A81B63&1761ADK56171A6&A61865156197C561
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=AD696A1188156191761+197C5616165561,$156197C561FFQ17B))D6B61
ADB81B63&1761932ADB86176153AB111
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8381%6DA61761A69%81V5
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'E 18)13%BAD61$1%361'#1
9991
1
1
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8B6996A1 531 DC561 31 3%%5B"6D1 6A1 61 8BA1 361 7681 A3%681
%DD688B696A1V5
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5%D3A6D1 61 %6A1 94B5B86D1 761 DC561 %D6&B8A3A61 6A1 7BA1 31 AD3BD61 )3BD61
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'66EA1
1
99B1
1
1
CPC Evaluation de la condition Effet sur la
performance
Qualité de la structure Très efficace Positif
organisationnelle Efficace Neutre
Inefficace Négatif
Déficiente Négatif
Conditions de travail Avantageuse Positif
Compatible Neutre
Incompatible Négatif
Qualité de l’IHM Très bonne Positif
Adéquate Neutre
Tolérable Neutre
Inappropriée Négatif
Disponibilités des procédures et Appropriée Positif
des plans Acceptable Neutre
Nombre d’objectifs simultanés Facilement gérable Neutre
Gérable Neutre
Ingérable Négatif
Temps disponible Approprié Positif
Temporairement approprié Neutre
Continuellement
inapproprié Négatif
Période de la journée Jour Neutre

Nuit Négatif
Efficacité de la formation et Appropriée, grande Positif
expérience expérience
Inappropriée, expérience Neutre
limitée Négatif
Inappropriée
Qualité de la collaboration Très efficace Positif

Efficace Neutre
Inefficace Neutre
Déficiente Négatif
Efficacité de la communication Appropriée Positif
Acceptable Neutre
Temps disponible Approprié Positif
Temporairement approprié Neutre
Continuellement
inapproprié Négatif
8>$6A111 B8A6176818E81AB5B868173815319A7618F(=H1
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B51 68A1 %88B4561 761 "35B)B6D1 531 8E81 +1>35BA1 761 531 5534D3AB1,1 8D1 61 65561
9921
1
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)AB696A17681556AB)81761AD33B5131AD36D8176819%DA696A81B7BB76581
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D6B6A131"35B)B6D156))6A17616AA618E818D1531%6D)D93617681%D3A6D81113B8B$1531
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1315317)3B5536171596A1%3DAB5B6D131D8176153ABBA1
61 %DBB%61 7W353AB1 68A1 B76AB"61 %D1 361 7681 8E8111 65BJB1
9%D671AA1734D711"68AB696A1618"6618D13617655681=B8B$1
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– 5335!8A61D68ABA6131%3DABD17681796A816A17681A9B36817681%6D8681
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'51(1353B8$1E2578928318BB)B61D35B86D1"65"6186$16176D81761AA19696A1761531"35BA1761
53A61(1)D3L3B8$161A6D961D6D6161AB1761D88BA6176153AB1
9931
1
1
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%D86A3AB17681%3DAB681%D63A681 3176&BC9617A3B556D31"3A131655615318ADAD61
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A6'71@A345631A1
1
1 Participent directement Participent indirectement
Influencent le projet Délégation Maîtrise des CRC Mines ParisTech

Risques MEDDTL
CRIGEN
Affectés par le projet
Influencent et sont affectés Salariés de sites pilotes Directeur d’Unité Réseau Gaz
par le projet Chefs d’Exploitation (DURG)
Exploitants délégués
8>$6.111H3ADB61761H3DA651373%A61
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11111111111111111111111111111111111111111111111111111111111
1 68138681B768176161A3456315618A13D1313A6D161DD68%71315317)BBAB1%D%861%3D1
'7
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9941
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1
Processus de développement « en Processus adapté au projet
cascade » OCÉANIE
Initiation du projet Initiation du projet
Spécification Spécification
Design Design
Programmation Prototypage
Test d'intégration Essais sur sites pilotes
Test d’acceptation Développement final et formation
Maintenance
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1
1
1
1
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6 Prototypage Essais sur Développement final et
sites pilotes déploiement
Délégation maîtrise Apport de la vision Pilotage des Lien avec la direction
des risques métier et de la sessions des services
connaissance des d’essai informatiques
contraintes Pilotage des formations
opérationnelles
Pilotes REX Premiers cadres

formés
Relais de la formation
aux salariés
CRIGEN Apport de la Soutien technique dans

connaissance la réalisation des
métier premières versions de
la grille d’analyse
CRC Mines Apport de la

ParisTech méthode CREAM
et de l’expertise
méthodologique
Salariés, CE Expression de Confrontation

besoins entre le design
spécifiques de la grille et
leurs
contraintes
opérationnelles
DURG et Soutien à la
exploitants démarche
délégués
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1
Module 1 :
compte rendu
de l’intervention
Module 2 : Analyse
de l’évènement
(existante ou à
créer)
Module 3 : Plan
d’actions
Module 4 : Pièces
1 jointes éventuelles
6
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1
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Simulateur d’étude Simulateur d’entraînement Simulateur scientifique
Repose sur la modélisation Ce type permet : Ce type de simulateur permet
mathématique. Il permet : 1 d’assurer une formation d’étudier le déroulement de
1 d’évaluer les performances initiale sans mobiliser des processus difficiles à
d’un système en cours de infrastructures coûteuses et observer naturellement de par
conception ; sans risques ; leurs caractéristiques
1 de former des opérateurs ; 1 de former des techniciens physiques.
1 de valider des déjà expérimentés à
équipements et des systèmes l’utilisation et l’entretien d’un
par des tests en situations matériel sophistiqué ;
normales ou extrêmes. 1 de réaliser des tests de
vigilance, de stress et de
résistance à la fatigue.
8>$6D1112!%5B6176818B953A6D81@Z5B35A$17A1
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Déroulement du REX Démarche inversée
Evènement Quels sont les indicateurs jugés
Description nécessaires à développer ?
Analyse A quelles demandes le système devra-

Saisie t-il répondre ?
Traitement Quel sera le contenu de la base de

Production d’indicateurs données et comment l’organiser ?
Réponse aux requêtes Quels sont les évènements à retenir,

comment les décrire et les analyser ?
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1
Stratégie Motivation Levier du Domaine Conditions Avantages
profonde changement d’implication
Collaboration Parce que Consultation et Modalités de mise Convergence Faible
c’est rationnel participation en œuvre culturelle, partage des résistance
objectifs, disponibilité interne faible
de temps, volonté résistance
d’implication, système externe
de communication utilisation des
compétences
Négociation Parce que Consultation et Objectifs et Reconnaissance d’un Faible
cela convient négociation modalités de mise pouvoir non résistance
en œuvre hiérarchique, interne, faible
disponibilité de temps, résistance
disponibilité à revoir externe
les objectifs
Emotion Parce que Implication Limité Convergence culturelle Vitesse du
c’est juste idéologique et faible, niveau de changement,
conviction conflit, présence d’un faible
personnelle leader charismatique, résistance
objectifs de interne,
développement transformatio
n culturelle
(changement
de culture)
Autorité Parce que Imposition Aucun Présence d’un pouvoir Vitesse du

c’est une hiérarchique, fort sens changement,
obligation de l’urgence, soutien capacité de
extérieur gérer les
crises,
capacité de
gérer les
conflits
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Modèle de Dekker Application de GrDF
Oui :
Crise : paralysie de la conception Crise due à plusieurs accidents majeurs
ancienne remettant en cause le statut de référence
de GrDF
Oui :
Remise en cause officielle de la
Déconstruire l’interprétation d’origine suprématie de l’approche technique et
procédurale de la sécurité ; adhésion à la
théorie des FHOSI
Non :
Perpétuation des politiques d’origine en
Mettre fin aux pratiques d’origine parallèle de l’insertion de la conception
nouvelle mais réaffirmation des
fondamentaux du professionnalisme
Oui/non :
Prise en compte partielle : intégration de
la notion d’environnement en lien avec
Identifier la source de la sécurité celle de comportements, mais
persistance de la croyance dominante
dans la sanction et le respect de la
procédure
Oui/non :
Développement de nouvelles contre- Développement de nouveaux outils
mesures d’analyse d’accident portant la nouvelle
conception
En cours de développement. Eléments
Apprendre à apprendre de résultats encore trop récents pour en
généraliser des leçons.
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Étapes de la vie Construction Gestion du Le manque de La culture de
de l’outil de l’outil processus par pédagogie l’organisation
l’organisation
Freins
Sensation de remise en
cause et crainte de la × ×
sanction
Coexistence avec un
système de ×
sanction préexistant
Difficulté d’évaluer les coûts
et les bénéfices du REX
× ×
Décalage entre le temps
long du REX et le temps
court des processus × ×
opérationnels
Instrumentalisation du
processus d’analyse
× ×
Interférences entre le REX
et les processus ×
concomitants
Durée du processus de
conception de l’outil
×
de l’outil × ×
Scepticisme des employés ×
Absence de gratifications ×
Invalidité des hypothèses
de la rationalité ×
instrumentale
Obstacles à la diffusion
horizontale de l’outil par les × ×
logiques de pouvoir
Existence de microcultures
à tendances centrifuges
×
Transversalité du REX ×
Opposition entre la logique
du REX et les cultures des ×
sous groupes
Manque de simplicité de
l’outil ×
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Mots clés : GrDF, facteurs humain et organisationnel, CREAM, retour d’expérience, simulateur,
gestion des risques, réseau distribution de gaz naturel.
A company facing the challenge of human and organizational factors
ABSTRACT : The industrial era and the subsequent development of the first modern socio-
technical systems led to the necessity of taking risk into account. This concept, thought before
the French Revolution on a theological basis, had to evolve in a more scientific direction. If the
technical aspect focused interest at first, the human and organizational dimension had to be
integrated, following major accidents. Risk management is a major concern for GrDF due to the
nature of natural gas. Created recently, this company inherited a strong preoccupation for the
reduction of risks. However, recent events demonstrated the existence of a threshold in this
progression. The need for change led to the development of two important projects concerning
the learning from past experience process and the formation process. First results show that a
major evolution is reshaping managerial and field behaviors. Some perduring limits illustrates
however that this change process faces strong resistance from an organization structured
around the paradigm of technical safety. This case study first aims at identifying the key factors
of success in such a process by developing a better understanding of managerial and
operational trade-offs through observation.
Keywords : gas network management, human and organisational factors, CREAM, common
performance conditions, accident analysis1

2012ENMP0098

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2012ENMP0098

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L’entreprise à l’épreuve des facteurs humain et

organisationnel : la pratique de l’analyse d’accident au

To cite this version:

HAL Id: pastel-00871806

HAL is a multi-disciplinary open access L’archive ouverte pluridisciplinaire HAL, est

Ecole doctorale n° 432 : Sciences et Métiers de l’Ingénieur

l’École nationale supérieure des mines de Paris

présentée et soutenue publiquement par

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