Accident findings

Ginzburg HM The psychological consequences of the Chernobyl accident—findings from the international atomic energy agency study. Public Health Rep 108 184-192, 1993... 

Obtain a copy of a report of the NTSB accident investigation of an airplane accident. Find out what procedures were followed, how many investigators participated, and what the findings were. 

Executive summary—Briefly summarizes the accident findings, conclusions, corrective actions, and how the investigation was managed. 

Summary of report findings and recommendations—Goes into more detail and explanation of the accident findings and what recommendations should be put in place (and why). 

Lalloo, R., A. Sheiham and J. Y. Nazroo (2003). Behavioural characteristics and accidents findings from the Health Survey for England, 1997, Accid. Anal Prev., 35,661-667. 

Avoid the temptation to overreact after an accident and install an excessive amount of protective equipment or complex procedures which are unhkely to be followed after a few years have elapsed. Sometimes an accident occurs because the protective equipment available was not used nevertheless, the report recommends installation of more protective equipment or an accident occurs because complex procedures were not followed and the report recommends extra procedures. It would be better to find out why the original equipment was not used or the original procedures were not followed. 

Step I - Select the combinations of systems that enter the analysis. (This is equivalent to finding accident sequences in event tree analysis.)... 

Step 3 - Partition digraph models into independent subdigraphs and find singleton and doubleton minimum cutsets of accident sequences. 

In the first 2.5 years of the precursor study, 169 significant precursors were identified for ihe 4. i2 reactor-years of operating experience represented by LERs submitted from 1969 to 1979. preliminary findings show 56 precursors for 126 reactor-years of operating experience for 1980-1981. The results were used to analyze accident sequences to estimate core melt frequencies lor operating plants and to compare these results with the estimates in existing PSAs. 

Previously, the facility had several mullimillion dollar accidents, and near misses. After each accident, investigations were made and corrective actions taken. However the large fire precipitated a risk evaluation of the entire mining complex to find latent accidents. 

Operators should be trained to look before they leap when they find valves wrongly set. See also Section 3.3.5 (a). Other accidents that occurred because operators failed to carry out simple tasks are described in Sections 13.5 and 17.1. 

After many years of improvements in technical safety methods and process design, many orgaruzations have found that accident rates, process plant losses and profitability have reached a plateau beyond which further improvements seem impossible to achieve. Another finding is that even in orgarriza-tions with good general safety records, occasional large scale disasters occur which shake public confidence in the chemical process industry. The common... 

This increase in productivity is accounted for partly by a decrease in absenteeism and accidents as well as a general increase in working efficiency. For example, Vernon (1918), found that when women in a munitions factory worked a 12-hour day they incurred 2.5 times more accidents than when they worked a 10-hour day. One of the more comprehensive studies of the effects of total hours of work was carried out after World War II by the U.S. Department of Labor (Kossoris and Kohler, 1947). This covered over 3500 men and women in 78 work units. Data were collected on accidents and absenteeism as well as productivity. The overall findings were that exceeding the 8-hour work day, 5 days/40 hours work week resulted in lower productivity and higher absenteeism and accident rates. 

When looking at one-time problems, it is important to consider whether this could have directly led to an undesired consequence, such as an accident or incident or a noncompliance situation, or if there is another level of safeguard. If it is concluded that the problem or weakness could have directly led to an undesired consequence, the system design should be reviewed to find a way in which a safeguard can be provided. Systematic issues require a redesign of the system to remove the potential for the problem. 

There arc oilier methods of hazard identification. A "wliat-if analysis presents certain questions about a particular hazard and then tries to find llie possible consequences of that hazard. The human-error analysis identifies potential human errors that will lead to an accident. They can be used in conjunction with llic two previously described methods.. ... 

Perform an event tree analysis to find tire path(s) an accident may follow... 

A fault tree is a grapliic teclmique used to analyze complex systems. The objective is to spotlight conditions tliat cause a system to fail. Fault tree analysis attempts to describe how and why an accident or otlier undesirable event lias occurred. It may also be used to describe how and why an accident or otlier undesirable event could take place. Thus fault tree analysis finds wide application in hazard analysis and risk assessment of process and plant systems. ... 

Lithium is extremely reactive with water and hydrogen peroxide. These are the only reactions which cause accidents. But one can find other dangerous reactions of this class of substances elsewhere in this Part (see p.146). 

The oxidising properties of these salts were described previously. It is not surprising to find a table of dangerous reactions for this type of oxidant. The problem may be aggravated by the frequency of these accidents since these salts are used in pyrotechnics. Indeed, they are the raw materials of all fireworks which produce green colours. 

Amides often give rise to accidents that are difficult to interpret because so many reagents are present and/or because of the complexity of the reactions that are brought into play. It is difficult to find a classification for this group. The first point is the fact that most accidents are due to dimethylformamide (DMF), which is much used as a polar aprotic solvent. When attempting to classify these types of dangerous reactions with this compound, as a model, it can be said that they are mainly due to ... 

---