Accidents basic causes

ETA breaks down an accident iato its contributing equipment failures and human errors (70). The method therefore is a reverse-thinking technique, ie, the analyst begias with an accident or undesirable event that is to be avoided and identifies the immediate cause of that event. Each of the immediate causes is examined ia turn until the analyst has identified the basic causes of each event. The fault tree is a diagram that displays the logical iaterrelationships between these basic causes and the accident. 

In a more quantitative sense, cause-consequence analysis may be viewed as a blend of fault tree end event tree analysis (discussed in tlie two preceding cliapters) for evaluating potential accidents. A major strengtli of cause-consequence analysis is its use as a communication tool. For example, a cause-consequence diagram displays the interrelationships between tlie accident outcomes (consequences) and Uieir basic causes. The method can be used to quantify the expected frequency of occurrence of the consequences if the appropriate chita are available. 

ANALYSIS DOCUMENTATION. PrHA report documentation should include the PrHA worksheets, checklists, logic diagrams, human reliability analyses, and any other analysis made to better understand the scenarios. The PSM Rule requires that human factors that impact scenarios as cause or protection be expanded to analyze the basic cause of errors or response failures. For example, a cause may identify that an operator can turn the wrong valve to initiate an accident. The PSM Rule requires that basic causes also be identified. For example, valve is not labeled the operator has not been trained on the operation or the operator forgot the step. There may be more than one basic cause. (See also Section 3.2, paragraph on Human Factors.)... 

On the tracks cross the basic idea is (Huang Xinwen 2009) damage accident was caused by... 

The casualties of non-professional rescue workers (coal miners) accounted for more than fifty percent of the total casualties of the secondary accidents (Table 2). The coal miners lacked of awareness of self-protection and had no knowledge of basic methods to handle disasters and rescue, so they obeyed the emergency rescue command of the coal mine managers blindly. Consequently thirty-three people were dead and twenty-five were hurt which together accounted for sixty-seven percent of all the casualties of them in secondary accidents. Three accidents were caused by coal miners who were desperate to save lives without identifying the reasons and basic protection measures. In addition, two accidents were caused by inappropriate measures during the rescue process which resulted in roof caving. 

Occupation/job title Number of years/months on job To whom was accident reported Describe medical treatment Basic cause code... 

The portion of the form calling for remedial measures read, Steps taken to prevent a recurrence. The answer Coached employee to exercise more caution when walking down the drift. Coaching the man to take more caution What about the hole Nothing was done about the hole or the lighting, which were the real causes of the accident. The hole is possibly still there to this day. The basic causes were never identified, but the finger was pointed at the employee. 

The Bird accident sequence revolutionized Heinrich s thinking in that Bird suggested the first domino, or initiating event, in the accidental loss causation sequence, was poor management control. This poor control, according to Bird, then triggered basic causes in the form of personal and job factors. These basic causes led to the unsafe acts or unsafe conditions. These immediate causes, as the acts and conditions are known, led to the contact with the source of energy and the resultant loss. Bird also included all aspects of accidental loss and not only personal injury. 

The second link in the accident sequence is lack of control. This lack of safety management control could be a weak safety systan in place, no safety system standards, noncompliance to the standards, or a total lack of a structured safety management system (SMS). This is often indicated by a negative or nonexistent safety culture. This triggers off the basic causes of accidents. If no formal SMS is in place, this would be classified as an inadequate control system. 

In regard to accident ratios, property damage accidents occur more often than any other type of accident. Property damage accidents are therefore opportunities to identify the basic causes and take steps to eliminate similar accidents. It will be appreciated that should a similar accident occur, because of hazards that have not been rectified, the outcome may be different. The next time the accident may result in injury, damage, business interruption, or a combination of these. 

The principle of the critical few states that a small number of basic causes could give rise to the majority of safety problems. A few critical tasks could be responsible for the majority of accidents and injuries occurring, and these items (aitical safety elements) should receive maximum safety control to minimize their potential for causing (the majority) of problems. 

Despite all that has been written about the workers behavior being the basic cause of the majority of accidents, the worker is in reality the person with the most knowledge about the workplace, work activities, and workplace risks. The worker is the expert and may have many years of experience doing a particular job, so why not consult him or her about the risks of the job and how to make it safer Perhaps we are so busy trying to fix the worker to prevent the accident that we have overlooked him or her as a source of safety information. A good policy is that if in doubt, ask the expert, and by speaking to the worker you will be speaking to the expert. 

Accidents are usually complex and are the result of multiple causes. A detailed analysis of an accident will normally reveal three cause levels basic, indirect, and direct. At the lowest level, an accident results only when a person or object receives the release of an amount of energy or exposure to hazardous material that cannot be absorbed safely. This energy or hazardous material is the direct cause of the accident. The second causal areas are usually the result of one or more unsafe acts or unsafe conditions, or both. Unsafe acts and conditions are the indirect causes or symptoms. In turn, indirect causes are usually traceable to poor management policies and decisions, or to personal or environmental factors. These are the basic causes. 

While we often think of hazardous acts and conditions as the basic causes of accidents, actually they are symptoms of failure on another level. Unsafe acts and unsafe conditions can usually be traced to three basic causes poor management policies and decisions, personal factors, and the physical facility design. 

We said that although unsafe acts and conditions appear to be the basic causes of accidents, they can actually be traced to such things as management safety policies and decisions, and personal factors. These things (managanent policies and decisions, personal and environmental factors) are the basic causes of accidents. 

First, we can prevent them by knowing what caused the accidents to happen in the first place. Accident investigators perform that task. The accident investigator determines the direct, indirect, and basic causes of an accident. But prevention does... 

A detailed description of the direct, indirect, and basic causes of accidents can be found in Chapter 7. Remember, the unplanned or unwanted release of excessive amounts of energy or hazardous materials causes most accidents. With few... 

We often think of unsafe acts and unsafe conditions as the basic causes of accidents. They are only symptoms of failure. The basic causes are poor management policies and decisions, and personnel and environmental factors. Fortunately, most employers now realize that safety and health must be a necessary part of the total operating system. These anployers take the responsibility to prepare a written safety policy and guidelines to instill safety awareness in their employees. Selection of best employees for the job, training, employee plaeanent, and the purchase of safe equipment and supplies are important to a successful accident prevention program. 

Every year many thousands die on the roads as victims of vehicular traffic accidents. This loss of life could be avoided if driving of motor vehicles were banned. There is no one who would consider this seriously. On the contrary, density of vehicular traffic increases every year and thus the danger of traffic increases as well. Safety science attempts to develop methods to provide optimal safety for the system motor vehicle-man-environment without wanting to do away with the basic cause for the death of man, motor vehicle traffic. 

Figure 12-3 The basic causes of an incident. OSHA s Smaii Business Outreach Training Program Instructional Guide, Web site, Accident Investigation, http //www. osha-slc.gov/SLTC/smallbusiness/sec6.html, public domain.

The NAI shall record findings on the Near Miss/Accident Investigation Report Form and both the immediate and basic causes of the event must be determined. The estimated costs of the losses should be entered on the form. 

Safety management control eliminates the basic causes of accidents and near miss incidents by setting up management systems, which include near miss incident cause rectification, and by delegating safety responsibility and accountability. This system... 

It has often been said that past experience usually predicts future trends. The same can be said for safety. Accidents that have occurred in the past tend to recur and the same basic causes also are present. Numerous near miss incidents often predict accidents. 

The objective is to define the methodology for reporting and investigating noninjury (loss-producing) accidents and near misses so that the immediate and basic causes of the events are identified and recommendations to prevent a recurrence are proposed and implemented. 

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