Accident investigation.Accidents

The results of these 41 accident reports might be symptomatic of maritime accident investigation. Accident investigation bodies apparently need time, resources, and expertise in order to address organizational factors. This includes a legal mandate to do this. 

Accident investigation Accident and record analysis Incident reporting and investigation... 

Accident investigation indicates that there are often many individual causes to an accident, and that a series of incidents occur simultaneously to cause the accident. The following figure is called the safety triangle", and shows the approximate ratios of occurrence of accidents with different severities. This is based on industrial statistics. 

Procedures are written to ensure that activities are performed in a systematic way. Accident investigation shows that the majority of accidents occur because procedures are not followed, and this contributes mostly to the base of the safety triangle introduced at the end of Section 4.1. 

Who investigates accidents (The toller, the client, both parties, third party, other specific site positions )... 

U.S. Government Printing Office, EPA/OSHA Joint Chemical Accident Investigation Report, Napp Technologies, Inc. Lodi, New Jersey. EPA 550-R-97-002. October 1997. 

Table 10.34 Data to record during accident investigation...

Investigate accidents which may have led to persons receiving effective doses in excess of 6 mSv or an equivalent dose greater than 30% of any relevant dose limit. Investigate and report to the authorities loss of materials from accidental release to atmosphere, spillages, theft. The Regulations provide a comprehensive list of notifiable concentrations for each radionuclide isotope. 

The employer investigates incidents that result in, or could result in, a catastrophic release of highly hazardous chemicals. An incident investigation is initiated as soon as possible, but before 48 hours following the incident. An incident investigation team is established to consist of one or more experts in the process involved, and accident investigation. The report prepared at the conclusion of the investigation includes at a minimum ... 

In addition to these formal studies of human error in the CPI, almost all the major accident investigations in recent years, for example, Texas City, Piper Alpha, Phillips 66, Feyzin, Mexico City, have shown human error as a significant causal factors in design, operations, maintenance or the management of the process. Figures 4.4-1 and 4.4-2 show the effects of human error on nuclear plant operation. 

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. 

Bulletin 3/96, Air Accident Investigation Branch, Defence Research Establishment, Famborough, UK. 

Baker and his colleagues (1983) compared the Strehlow et al. (1979) curves to experimental data, then applied them in research programs, accident investigations, and predictive studies. They developed the methods for use of Strehlow s curves. 

Maintenance (Mechanical Integrity) —Pre-Startup Review —Management of Change —Safety Audits — Accident Investigation... 

One of the origins of this view of error and accident causation is the theory of accident proneness, which tried to show that a small number of individuals were responsible for the majority of accidents. Despite a number of studies that have shown that there is little statistical evidence for this idea (see, e.g., Shaw and Sichel, 1971) the belief remains, particularly in traditional industries, that a relatively small number of individuals accoimt for the majority of accidents. Another element in the emphasis on individual responsibility has been the legal dimension in many major accident investigations, which has often been concerned with attributing blame to individuals from the point of view of determining compensation, rather than in identifying the possible system causes of error. 

The focus of this chapter has been on proactive application of these analytical methods such as safety audits, development of procedures, training needs analysis, and equipment design. However, many of these methods can also be used in a retrospective mode, and this issue deserves further attention in its own right. Chapter 6 describes analytical methods for accident investigations and data collection. 

Typically, the first phase of a comprehensive accident investigation process will involve describing the way in which the hardware, the chemical process, individual operators and operating teams are involved in the accident process. This is the domain of the structural analysis techniques and the technical analysis of the chemical process which gave rise to the accident. Analyses of human error will primarily address the interactions between hardware systems and individuals or operating teams (the first two layers... 

Planned changes should be documented as part of a formal change monitoring process (for example via a quality assurance system). Unplanned changes should be identified during the accident investigation process. 

Ferry, T. S. (1988). Modem Accident Investigation and Analysis (2nd edition). New York Wiley. 

Hendrick, K., Benner, L. Jr. (1987). Investigating Accidents zvith STEP. New York Marcel Dekker. 

Accident investigation Procedures - to e aluatc any EHS accidents that occur, with the focus on prevention of a recurrence... 

Trade union safeQ reps have the right to cany out inspections and investigate accidents. 

Investigating accidents is a useful way of reviewing your safety systems - ask yourself why the accident really happened and what you can do to stop it happening again. 

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