Accident reporting, system safety

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. 

Member States have the obligation to report major accidents to the Commission. In order to fulfill its information obligations toward the Member States, the European Commission has created the Major Accident Reporting System (MARS) database to store and retrieve accident information reported by the Member States, and a Community Documentation Centre on Industrial Risks (CDCIR) was established to collect, classify, and review materials relevant to industrial risks and safety. 

Time-loss analysis is a special-purpose technique used to evaluate accident responses. System Safety Development Center courses that teach the technique credit the National Transportation Safety Board (specifically Driver and Benner) with developing and reporting the technique. 

BP s own reports during the years immediately before the accident reported multiple safety system deficiencies, and included the following comments and statements (as detailed in the report by the US Chemical Safety and Hazard Investigation Board) ... 

Example 3 An evaluation of the accident-reporting system of an offshore installation showed that remedial actions were identified before and independently of the identification of causal factors based on the ILCI model. This classification of causal factors was done in order to satisfy formal requirements rather than as a tool in order to come up with better safety measures. 

Experiences of the British Airway Safety Services (BASIS) near-accident reporting system support the use of a form for self-reporting with open-ended questions according to the first principle (Reason, 1997). BASIS first tried a form with questions concerning types of human errors and contributing factors, where the answers were given in a multiple-choice format. The resulting data suffered from poor validity and reliability. 

Students of the management of safety will usually observe that companies systems for feedback control of accidents are far from ideal. There are many examples in the literature of the shortcomings in, for example, companies accident and near-accident reporting systems. A number of technical, organisational and motivational obstacles have to be overcome in order to accomplish efficient feedback. 

U. S. Department of Transportation. National Highway Traffic Safety Administration. Fatal Accident Reporting System 1984 DOT HS 806 919 (February 1986). Chapter 2, p. 1. 

A National Transportation Safety Board Railroad Accident Report (1973) describes the accident which occurred in a shunting yard in East St. Louis, Illinois. Arriving cars are classified in the yard, then delivered to outbound carriers. On arrival, cars are inspected. They are then pushed up a mound, uncoupled, and allowed to roll down a descending grade onto one of the classification tracks. This process is called humping. Cars are directed and controlled by a computerized switching and speed-control system. 

National Transportation Safety Board. 1979. Pipeline Accident report—Mid-America Pipeline System—Liquefied petroleum gas pipeline rupture and fire, Donnellson, Iowa, August 4, 1978. NTSB-Report NTSB-PAR-79-1. 

Reason J., 1991. Too little and too late a commentary on accident and incident reporting systems, in Schaaf van der, et al. (Eds.), Near miss reporting as a safety tool, Butterworth Heinemann, Oxford. 

Lucas (1992) proposes that different safety cultures will have an impact on which accidents are investigated and whether or not near miss reporting is perceived as a valuable use of resources an occupational safety culture would probably investigate only serious personal injuries the risk management culture might be interested in certain types of near misses with very direct and serious potential safety consequences finally a systemic safety culture will encourage its employees to report anything related to possible deviations, either with immediate or delayed consequences for safety control. 

The most frequently reported systemic adverse events were hypertension, arthritis, urinary tract infection, and hypercholesterolemia. Of the 36 patients reporting a serious adverse event, 11 exited the study for that reason. Serious adverse events were reported by 23 of the 98 anecortave acetate-treated patients and 13 of the 30 placebo-treated patients. Five deaths from lung carcinoma, heart failure/ cerebrovascular accident, accidental injury, or myocardial infarction were reported. However, none of these serious adverse events or deaths was assessed as related to study treatment. An independent safety committee concluded that there were no clinically relevant medication-related or administration-related safety concerns. 

Lessons-learned programs are not the only way of capturing deviant conditions and potential solutions. Accident and incident reports are useful in themselves even though many form the basis for lessons learned. They alert people to potential safety issues so that the same adverse event is not repeated inadvertently. Near-miss reporting systems can be even more proactive as they allow personnel to avoid potential events as well as actual events. 

It would be useful to check these impressions against the official statistics on occupational risk collected by the Bureau of Labor Statistics (BLS), but these are notoriously unreliable. Indeed, the National Research Council, an offshoot of the National Academy of Sciences that reports on public policy issues, found the BLS data inadequate for monitoring the effectiveness of safety programs (Saddler, 1987). There are several problems. First, the data are collected as part of the Occupational Safety and Health Act (OSHA) reporting system, which subjects them to distorting incentive effects. Firms are required to maintain logs of fatal and nonfatal accidents, but they have an incentive to underreport this information since it could be used as evidence to support workers compensation or tort claims by workers, and because... 

In some industries, system safety is viewed as having its primary role in development and most of the activities occur before operations begin. Those concerned with safety may lose influence and resources after that time. As an example, one of the chapters in the Challenger accident report, titled The Silent Safety Program, lamented ... 

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