Accident review boards

The primary duties of the accident review board is to determine the cause and responsibility of serious accidents or a pattern of accidents, and to make recommendations that will prevent similar occurrences. The members of the board are typically supervisor level employees appointed by management. Members must be objective in performing their duties. The board may hold accident hearings, as discussed in the section Record Keeping and Accident Investigation in this chapter. 

As mentioned earlier, determining an accident trend analysis should be relatively easy. In principle, at least, it is easy, or it should be however, a variety of obstacles will probably be encountered when trying to determine the current status of safety culture. In the initial chapters, we discussed how an OSHA log can be a guide to potential problem areas. OSHA logs, accident reports, incident investigations, accident review boards, medical records, worker interviews, OSHA citations, and other information can provide a lot of information about safety culture development. 

A I have asked our Corporate VP for Operations to take day-to-day oversight of the work. I expect to review progress every month. I will make sure that the project has all the resources and management commitment needed to make it succeed. I have already planned for an annual reduction in accident and incident related costs of at least 10 percent each year. I have given my personal commitment to the board that we will achieve this. 

National Transportation Safety Board. A review of flightcrew-involved major accidents of U.S. air carriers, 1978 through 1990. NTSB Safety Study SS-94/01. Springfield, VA National Technical Information Service, 1994. 

Until a few years ago, it was widely believed that if a worker was involved in an accident while performing their duties, it was probably the worker s fault. In a review of 75,000 accident cases, an estimated 88 percent of the accidents were due to unsafe acts of people. Similarly, airplane accidents were generally assumed due to human error— the pilot. U.S. Air Force ballistic missiles introduced a new concept of the cause of accidents. When the missiles were launched and then failed, there was no human on board to blame. Thus, the cause of the accident was due to something else, such as design or manufacturing error. This led to the new concept that accidents could be caused by an error due to ... 

In order to carry out the review of accident investigation reports into machinery space fires and explosions on board merchant ships, the HFACS framework had to be slightly adapted. The adapted framework is shown in Fig. 2. More detailed explanation with regard to the adaptations can be formd in Ghirxi (2008). 

National Transportation Safety Board. Annual review of aircraft accident data U.S. general aviation. Calendar year 2003. (Publication No. ARG-07-01, adopted on November 29, 2006). Retrieved December 07, 2008 from NTSB . 

National Transportation Safety Board (2004), U.S. General Aviation, Calendar Year 2000, Annual Review of Aircraft Accident DataNTSB/ARG-04/01, Washington, DC National Transportation Safety Board. 

Minority reports (if necessary)— May be included if the board is not in 100% agreement to what caused the accident. This does happen, and for very large and severe accidents, it may be necessary to have a section to allow minority or contrarian reviews to be put forth. This is very important to show impartiality, transparency, and differing views. Bnt in the end, some sort of majority conclusion and recommendations must be made so that the company can move forward. 

As with almost aU incidents, in hindsight it is easy to identify the cause(s) of the event and the procedures that could have easily prevented this from occurring. It is probably inaccurate to characterize the Bhopal disaster as an accident since this implies a certain statistical randomness to the event. In this incident, people took overt actions that caused the event to occur, removed safety systems that could have minimized the effects of the initial mistake, and failed to adequately prepare for the disaster. A recent video produced by the Chemical Safety Board reviews this incident 30 years afterwards and commends improved state and federal regulations regarding process safety management (See Section 7.3.7.)... 

Based on this review and previous analysis of RSPA data, the Safety Board concludes that deficiencies in RSPA accident data, particularly with respect to the cause of accidents and a record of whether those involved in pipeline accidents... 

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