Accident investigation corrective actions

Nonconforming product investigation rework records include investigation/corrective action (no blends to reduce adulterants unless CBER approved reduction method) no microbial positive rework complaints, recalls, errors, and accidents adverse experience reports all tracked and reported as required (Identity-610.14 purity-610.13). 

Almost immediately after the TMI-2 accident, the government and the nuclear industry sought to identify the causes and began taking steps to reduce the likelihood of future accidents. Extensive corrective actions for U.S plants were required by the NRC s TMI Action Plan (see Section 1.4.6). The first and most prominent formal investigation of the accident was conducted by the President s Commission on the Accident at Three Mile Island, also known for its chairman, John Kemeny. Two important NRC-sponsored investigations were by... 

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. 

Incident and accident investigation reports and corrective actions taken... 

In one case the team determined that an injury accident had been caused, in part, by a block valve being left in the closed position when it should have been open. The company had many other similar facilities. Therefore, two members of the investigation team toured those sites to ensure that the equivalent valve at those sites was open and tagged. Also, each site crew was briefed as to what had happened. Finally, on the following day, the safety manager issued a company-wide bulletin in which all managers were told of what had happened, and what immediate corrective actions to take. 

Accident Report—Records the findings of an accident investigation, the cause or causes of an accident, and recommendations for corrective action. 

After one of my presentations, an attendee spoke to me about the poor quality of incident investigation reports that reached her desk. I had spoken of the need to emphasize systems causal factors and to get away from the excessive concentration shown in some of their investigation reports on what the worker had done in the accident process. She said that almost all of the investigation reports that came to her desk suggested a corrective action that would improve worker behavior, and stopped there. 

A future chapter will be devoted to effective incident/accident investigations. Every incident (near miss) or accident provides a continuous improvement opportunity that should result in root cause analysis and corrective actions. Here is a chance to utilize someone with a passion for lean, and his/her problem-solving skill sets, to fill this safety team position. Eilling this role provides another opportunity to develop a future business leader. 

Accident/incident investigation subteam This team is accountable for the continuous improvement of safety by using every incident and accident as a vehicle to get to root causes and corrective actions. The... 

Lead all accident investigations using lean tools to get to root cause and corrective actions. 

Root cause The one cause that leads all of the others when conducting an investigation of an outcome. In accident or safety incident investigations, the pursuit of effective corrective actions is dependent on defining the root cause of the accident or incident. 

Warnings went unheeded - Findings indicated that most incidents were often preceded by a series of smaller accidents, near misses, or accident precursors. Operations and maintenance procedures must include analysis, root cause investigation, and corrective action. 

Investigate accidents and near-miss incidents and take corrective action... 

Monitor leading indicators using the Safety Scorecard Identify and report incidents, near misses, and unsafe conditions Track accident investigations and store causal factor data Assign and manage corrective actions / Collaborate with multiple departments for incident resolution Monitor the status of tasks and projects Manage OSHA-recordable and other injury records... 

Root causes must be identifled and appropriate corrective action implemented. The accident analysis may be performed by the SSWG and/or by other boards of investigation, but the necessity for systematic, in-depth accident analysis is an integral part of the system safety effort. 

In 1910, the U.S. Bureau of Mines was created by the Department of the Interior to investigate the causes of mine accidents, study health hazards, and find means for taking corrective action. 

Identification of hazards includes those items that can assist you in identifying workplace hazards and determining what corrective action is necessary to control them. Actions include worksite safety inspections, accident investigations, meetings of safety and health committees, and project safety meetings. To accomplish the identification of hazards, the following should be reviewed ... 

Conducting investigations of accidents, near-misses, and property damage, and preparing reports with recommended corrective action... 

In the courses being taught on incident investigation, the instructor leads attendees to conclude that 80-90% of accidents are principally caused by the unsafe acts of workers and that the corrective actions proposed should focus... 

Many accident investigations do not go far enough. They identify the technical cause of the accident, and then connect it to a variant of operator error. But this is seldom the entire issue. When the determinations of the causal chain are limited to the technical flaw and individual failure, typically the actions taken to prevent a similar event in the future are also limited fix the technical problem and replace or retrain the individual responsible. Putting these corrections in place leads to another mistake—the behef that the problem is solved. 

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