Accident and Incident Reporting

OTHER TOOLS THAT CAN BE USED FOR HAZARD CONTROL Accident and Incident Reporting 

Accident and incident reporting process allows for the identification of hazards as well as the development of controls for the removal or mitigation of hazards. All incidents and accidents resulting in injury or causing illness to employees, and all events or (or near-miss accidents) must be reported to 

OCCUPATIONAL HEALTH AND SAFETY MANAGEMENT A PRACTICAL APPROACH 

Less effective Training and procedures (administrative controls) 

Establish a written record of factors that caused injuries and illnesses or that caused occurrences (near-misses), which might have resulted in injury or illness but did not do this for bodily, property, and vehicle damage, and occurrences. 

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Reason J., 1991. Too little and too late a commentary on accident and incident reporting systems, in Schaaf van der, et al. (Eds.), Near miss reporting as a safety tool, Butterworth Heinemann, Oxford. 

Lessons-learned programs are not the only way of capturing deviant conditions and potential solutions. Accident and incident reports are useful in themselves even though many form the basis for lessons learned. They alert people to potential safety issues so that the same adverse event is not repeated inadvertently. Near-miss reporting systems can be even more proactive as they allow personnel to avoid potential events as well as actual events. 

Gather lessons learned in operations (including accident and incident reports) and use them to improve the development processes. Use operating experience to identify flaws in the development safety controls and implement improvements. 

C.W. Johnson. 2003. Failure in Safety-Critical Systems A Handbook of Accident and Incident Reporting, University of Glasgow Press, http //www.dcs.gla.ac.uk/ jolmson/ book... 

Accident and incident reports Operations reports Maintenance reports Charige reports Whistleblowers... 

The practicalities of implementing these various points will vary from organisation to organisation but any weaknesses in accident and incident reporting systems can usually be identified quite easily in the comse of a straightforward review of the systems against the criteria listed above. 

A similar picture emerged when Jentsch, Hitt and Bowers (2002) examined the 61 aviation training issues contained within Funk and Lyall s (1997) human-automation interaction database of accident and incident reports, interviews, research reviews, and questionnaire data. Jentsch, Hitt and Bowers (2002) used an information processing model similar to that proposed by Nagel (1988) to classify automation-related problems. The results indicated that 86.9 per cent of issues were associated with perception and decision-making, while only 13.1 per cent of issues were associated with the action stage of human performance. Similarly, in air traffic control, 91.1 per cent of problems emerging from the introduction of a new air traffic control facility were classified as perceptual or decision-related in nature, while action issues accounted for only 8.9 per cent of concerns (Jentsch, Hitt and Bowers, 2002). 

Attimdes, policies, training manuals, procedures, formal statements, bulletins, accident and incident reports, job descriptions, minutes of meetings... 

Usability of accident and incident reports for evidence-based risk modeling of ship grounding... 

The paper is organized as follows Section 2 introduces the accident and incident reports that are used for the study. The applied methodology for reviewing the reports for evidence-based modeling is presented in section 3. Section 4 presents the obtained results, whereas Section 5 discusses them. Section 6 concludes the paper. 

Since the accident and incident reports are reviewed with different approaches, in order to be able to compare the extracted knowledge from them we transferred the results of the accident reports to the categories used for the incident reports (Table 2). Small Spearman rank correlation (p 0.03) between the rank orders of causes for accident and... 

For instance, although errors has the second rank in frequency in both types of reports, based on the frequency of inappropriate communication and cooperation in the accident and incident reports, we may conclude that appropriate communication and cooperation in the incident cases stopped the situation to become serious that it would result in an accident thus highlighting the importance of a proper interaction between the crew. This conclusion can be confirmed at some level by the statistical results of the study. Inappropriate communication and cooperation is linked to inappropriate route planning (r = 0.5,/ <.05) in the accidents. The importance of appropriate route planning, itself, can be understood by the link that it has with presence of a pilot (r = 0.5, /> <.05) in accident cases, knowing that in 64% of the reviewed accident reports a licensed pilot was present onboard the vessel. It is worth to mentioned that there is a strong link between inappropriate communication and personal factors (r = 0.7, <.001) in incident reports, which can show how personality of crew affects the safety through inappropriate communication. 

The results show that the most frequent active failure contributed in the reviewed grounding accidents is the operator errors in decision or judgment, as it comes the second most frequent causes in both accident and incident reports. Combining this knowledge with the high/low frequencies of inappropriate communication and cooperation in accident/incident reports respectively, the importance of proper interaction between the crew members may be highlighted. Most of the operator... 

Eigure 5.3 Reprinted from Too little and too late A commentary on accident and incident reporting systems Reason, 1991 In Near Miss Reporting as a Safety Tool Van der Schaaf, T.W., Lncas, D.A. and Hale, A.R. (eds) by permission of Bntterworth Heinemann Pnblishers, a division of Reed Educational Professional Publishing Ltd... 

The accident data presented in this section are predominantly gathered from the Marine Accident Investigation Branch (MAIB). The MAIB is a totally independent unit within the Department of the Environment Transport and the Regions (D ) and reports directly to the Secretary of State. The MAIB received 1,418 accident and incident reports in 1999. Accidents to ships accounted for 641 of those reports. 

Johnson C (2003) FaRure in safety-critical systems a handbook of accident and incident reporting. University of Glasgow Press, Glasgow... 

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