Accident Investigation experience

Place emphasis on adoption and application of the accident investigation experiences and lessons... 

Toward this end, the task group (called the Accident Investigation Committee, or AIC) was put together from a group of carefully chosen individuals to bring together the desired mix of skills and expertise. The chosen individuals contributed a broad range of experiences ... 

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). 

ABSTRACT While probing into the investigation mechanism for the accidents occurring in American coalmines, the differences of the enforcement basis and mechanisms on the coalmine accidents between China and USA are compared and analyzed. Furthermore, the problems of China in the accident investigation mechanism are reviewed in a scientific, independent and systematic approach. Then, the author suggests the American advanced experiences and operations should be learnt, and subsequently comes up with the countermeasures for improving the investigation mechanism of China. 

Improve the accident investigation philosophy The philosophy and aim orientation of the accident investigation shall focus on improvement of safety and avoidance of accidents, analysis of the radical causes of the accidents, and learning of experiences and lessons. These measures serve as the important grounds for relevant department, industry and enterprise to formulate standards. Their implementation is supervised and tracked, so as to avoid reoccurrence of similar accidents. 

The results of operating experience, process hazard analyses, audits, near misses, or accident investigations are used to improve operations and the safety control structure. 

In examining the impact of economic deregulation on safety in the aviation industry, the literature surveyed in the previous chapter provides an excellent starting point. In particular, two books based on interviews with airline pilots, mechanics, FAA inspectors, accident investigators, and others (O Malley, 1993 Nance, 1986) provide first-hand perspectives on experiences in the aviation industry in the years after deregulation. These books serve as a useful supplement to the statistical analyses and other empirical data stunmarized in Chapter 2, and provide detailed information based on extensive interviews. 

A detailed, defined, and recorded review of an incident undertaken to identify and record the causes and contributing factors and their relationships, which led up to and caused the incident. Accident Investigation is a technique that allows an organization to learn from its experience. The intent of an incident investigation is for employers to learn from past experiences and thus avoid repeating past mistakes. See also Incident Investigation Team. 

System to analyze injury and illness trends over time through a review of injury/ illness experience hazards identified through inspections, employee reports, and accident investigations... 

An electrical maintenance supervisor with 15 years of experience ordered his assistant to deenergize a machine they were about to service. Before the assistant could cut the power, the supervisor reached into the back of the unit, made contact with bare leads, and was electrocuted. The supervisor had been an outstanding employee with no record of accidents or related lost workdays, but he had violated several company safety policies while performing this task. An electrician with his years of experience should never have made the mistakes he made. The results of the accident investigation revealed the... 

The material in this chapter is a combination of information obtained and developed by the Occupational Safety and Health Administration (OSH A) and the Mine Health and Safety Administration based on their experience in conducting accident investigations over a period of many years. 

When accidents are not reported, their causes usually go uncorrected. This allows the chance for the same accident to happen again. Every accident, if properly investigated, serves as a learning experience for the people involved. However, investigations should not become a mechanical routine. They should strive to establish what happened, why it happened, and what must be done to prevent a recurrence. An accident investigation must be conducted to learn the facts, not to place blame. 

Using the company s accident investigation forms, the first thing to do in analyzing the accident is to read the narrative and visualize what happened. Often, the report is sketchy, but most of the time you will be able to draw on your experience to read between the lines and get the picture. Once you have visualized the situation and what occurred, then ask What could have prevented this accident To help determine the appropriate preventive measures, make use of the list of physical barrier analysis statements. The following statements refer to each of the four types of physical barriers. For each type, there are four possibilities. Select the one that best represents a valid opinion of the accident. 

A minimum of four years experience in Accident Investigation or Road Safety Engineering. 

A minimum of two days CPD in the field of Road Safety Audit, Accident Investigation or Road Safety Engineering experience in the past 12 months. 

The data obtained in the measurements showed that about 1% of the iodine inventory of the central fuel module reached the blowdown suppression tank, while only 0.23% of the cesium inventory appeared there. These data and those taken from the simulated broken line indicated that cesium deposited in this line more readily than iodine the reverse situation occurred in the upper plenum of the reactor pressure vessel. Here, almost no cesium was detected on the deposition coupons while iodine was present in amounts similar to those in the line of the low-pressure injection system. Besides iodine, silver was found on the upper plenum coupons in equivalent amoimts in addition, the iodine deposited on these coupons could not be leached by water, indicating that it was present there as an insoluble compound. From these data it was concluded that fission product iodine was transported out of the reactor core as Agl, rather than as Csl. Formation of Agl as the main iodine compound deposited in the upper plenum of the reactor pressure vessel is a behavior markedly different from that observed in other in-pile experiments and in the TMI-2 post-accident investigations. The reason for this behavior was assumed to be the low concentrations of both cesium and iodine present in the low-bumup fuel, which resulted in a very high stoichiometric excess... 

Reference is made several times in this book to an organization s safety culture and how it impacts on the injury experience attained, favorable or unfavorable. Since causal factors for incidents resulting in serious injury are largely systemic and their accumulation is a reflection of the organization s safety culture, that subject must be explored. Comments made on organizational culture in the August 2003 Report of the Columbia Accident Investigation Board on the Columbia space ship disaster are pertinent here. They follow. 

While work accidents regularly have multiple causes that can be identified by a thorough accident investigation process, some general sources of loss can be identified based on the long-term experience with constmction safety issues ... 

The leader of the accident investigation team should be chosen as soon as possible after the accident occurs. Management must designate or approve the leader and other members of the team. If a written investigation procedme has been estabhshed, this can be carried out automatically. Management is not required to approve the participation of the health and safety representative. The health and safety representative has a right to be involved with the investigation. The leader should have the authority to get the job done, and the experience to do it. 

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