Accident Investigation System

A comprehensive accident investigation system, as well as training, was implemented, and line management were made responsible for their own accident investigations assisted by safety staff where and when necessary. A vehicle seat belt policy and windshield stickers were introduced, and the gate security guards instructed not to allow any vehicle onto the site if the occupants were not wearing their seat belts. They also reminded vehicle occupants to bnckle np. 

To determine which near miss incident should be investigated via the accident investigation system, each near miss incident should be risk ranked as to potential loss and frequency of recurrence. In Model 7.8 are a few examples from industry of reported near miss incidents that have been ranked on a simple low (1), medium (2), medium-high (3), high (4) scale. ... 

Once the investigation is completed, the hazards need to be eliminated. If the loop is not closed, the same risks will eventually lead to a loss-producing event. The hazard must be eliminated and a follow up done to ensure the ranedial action is completed. This is a weak area in many near miss incident and accident investigation systems. 

The first step in developing an accident investigation system is to set up a system that allows employees to report accidents (without retribution). If employees fear for their jobs, not only will they not report accidents, they will also hide information that could possibly prevent accidents. And of course companies are obligated by law to post any reportable injury. A reportable injury is an occupational death, injury, or illness that must be recorded on OSHA Form 200, Log of Occupational Injuries and Illnesses. Other countries have comparable reporting systems. 

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. 

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. 

Three major themes have been emphasized in this chapter. The first is that an effective data collection system is one of the most powerful tools available to minimize human error. Second, data collection systems must adequately address underlying causes. Merely tabulating accidents in terms of their surface similarities, or using inadequate causal descriptions such as "process worker failed to follow procedures" is not sufficient to develop effective remedial strategies. Finally, a successful data collection and incident investigation system requires an enlightened, systems oriented view of human error to be held by management, and participation and commitment from the workforce. 

Sulphuric acid at 93% was added to p-nitrotoluene. The temperature reached 160°C due to a failure of the thermal control system. The sulphonic acid formed decomposed violently at this temperature. The post-accident investigation showed that the decomposition started between 160 and 190 C. In fourteen minutes the temperature rose to 190-224°C and in one minute and thirty seconds to 224-270°C. A large volume of gas was then released during the eruption. The phenomena caused by the decomposition of nitrated derivatives in the presence of sulphuric acid will be addressed several times. What these incidents have in common is the formation of large carbonised volumes. This phenomenon is common with sulphonic acids. The nitro group role is to destabilise intermediate compounds and final compounds and to generate... 

Describe why accident investigation recommendations must include recommendations to improve the management system. 

As stated in section 12-4, the three layers of recommendations for accident investigations include management systems to prevent similar accidents or to eliminate the hazardous conditions. This management system includes the delegation of responsibilities and followup. What are the benefits of followup Compare your answer to the benefits described in the CCPS (1992) reference on p. 238. 

A management system for accident investigations includes good communications. What are the tangible benefits of a good communications system Compare your answer to CCPS s (1992, p. 238). 

An accident investigation at the Tosco Refinery Company emphasized the importance of a management system. Describe the accident, and develop three layers of recommendations. See http //www.chemsafety.gov/. 

The accident investigation at Lodi, New Jersey, included previous industrial accidents with sodium hydrosulfite and aluminum. Summarize the findings of these accidents and develop a few management system recommendations for these industries. See http // www.epa.gov/ceppo/pubs/lodirecc.htm. 

Illustrate the layered accident investigation process, using Example 13-1 as a guide, to develop the underlying causes of the duct system explosion described in section 13-1. 13-2. Repeat Problem 13-1 for the bottle of isopropyl ether accident described in section 13-2. 13-3. Repeat Problem 13-1 for the nitrobenzene sulfonic acid decomposition accident described in section 13-2. 

In 1990, the National Transportation Safety Board (NTSB) completed a study of 182 fatal-to-the-driver truck accidents to investigate the probable cause of the accidents. While the study was designed under the assumption that most fatal heavy truck crashes may be related to alcohol and other drugs, it was found that the most frequently determined probable cause was fatigue (12). A 1993 analysis of the Fatal Accident Report System (FARS) also suggested that truck driver fatigue is a contributing factor in about 30% of heavy truck accidents. 

Every laboratory should have an internal accident-reporting system. This includes provisions for investigating the cause of an injury as well as any potentially serious incident that does not result in injury. The primary aim of such investigations should be to make recommendations to improve safety, not to assign blame for an incident. Local legal regulations may require reporting procedures for accidents or injuries. 

Accident Investigation is like peeling an onion or, if you prefer amove poetic metaphor, the dance of the seven veils. Beneath one layer ofcauses and recommendations there other less superficial, layers. The outer layers deal with the immediate technical causes while the inner layers are concerned with ways of avoiding the hazards and with the underlying causes such as weaknesses in the management system. Very often only the outer layers are considered and thus we fail to use all of the information for which we have paid the high price of an accident.. . . ... 

Thorough and effective analyses of workplace incidents are critical components of a comprehensive safety management system. Yet, many incident analysis processes (i.e., accident investigations) fall short. They frequently fail to identify and resolve the real root causes of injuries, process incidents and near misses. Because the true root causes of incidents are within the system, the system must change to prevent the incident from happening again. 

ABSTRACT Four hundred and sixty seven coal gas explosion accidents that occurred in China between the years of 1950 and 2000 were investigated through statistical methods so as to review the overall situation and provide quantitative information on coal gas explosion accidents. Statistical characteristics about accident-related factors such as space, time, gas accumulation reasons, gas grade, ignition sources, accidents categories, and accident economic loss were analyzed. Some special conclusions have been achieved. For example, most gas explosion accidents were found to have concentricity on the space-time and hazard characteristics. Such results may be helpful to prevent coal gas explosion accidents. Moreover, comments were made on APS (Accident Prevention System) and safety culture. In conclusion, countermeasures were proposed in accordance with the results of statistical studies, including the change of safety check time. 

Vol. 30 Mineral Resources (1998) is the rules for implementation stipulated in accordance with the Mine Act. Also, statutory standard on mine safety and health can be proposed and revised as needed every year. Other coalmine safety-related regulations include Coal General Inspection Procedures Handbook and Inspection Tracking System and 1970 Occupational Safety and Health Act, etc. Systematic, complete and strict legal system in American mine safety has become the first requisite for the country to ensure its accident investigation to be scientific and reasonable [ZHAO Jun et al. 2008, ZHANG Chuanbao JIA Xiuhua 2011]. 

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