Accidents corrective action

Preventable Accident Corrective Action/Disciplinary Schedule... 

Develop and communicate a progressive written preventable accident corrective action disciplinary schedule that is consistently enforced throughout the entire company. Use the sample template found in this section as a model. 

A technique called probabiUstic safety assessment (PSA) has been developed to analy2e complex systems and to aid in assuring safe nuclear power plant operation. PSA, which had its origin in a project sponsored by the U.S. Atomic Energy Commission, is a formali2ed identification of potential events and consequences lea ding to an estimate of risk of accident. Discovery of weaknesses in the plant allows for corrective action. 

HAZOP (Knowlton, 1989 Lees, 1980 CPQRA, 1989, pp. 419-422). HAZOP stands for hazard and operability studies. This is a set of formal hazard identification and elimination procedures designed to identify hazards to people, process plants, and the environment. The techniques aim to stimulate in a systematic way the imagination of designers and people who operate plants or eqmpment so they can identify potenti hazards. In effect, HAZOP studies make the assumption that a hazard or operating problem can arise when there is a deviation from the design or operating intention. Corrective actions can then be made before a real accident occurs. 

Previously, the facility had several mullimillion dollar accidents, and near misses. After each accident, investigations were made and corrective actions taken. However the large fire precipitated a risk evaluation of the entire mining complex to find latent accidents. 

Evaluate Effectiveness on the Basis of Outputs and Acceptance Once the system has been implemented on its chosen site, its effectiveness needs to be evaluated at frequent intervals so that corrective action can be taken in the event of problems. The first criterion for success is that the system must generate unique insights into the causes of errors and accidents, which would not otherwise have been apparent. Second, the system must demonstrate a capability to specify remedial strategies that, in the long term, lead to enhanced safety, environmental impact and plant losses. Finally, the system must be owned by the workforce to the extent that its value is accepted and it demonstrates its capability to be self-sustaining. 

Some measures of PSM and ESH performance are easy to identify, establish and track. These include accident rates, effluent tonnages and composition and number of days lost to illness. Almost all of these traditional performance measures are end-of-pipe that is, they measure the output of the management system and allow corrective action only after a failure has occurred. The ideal measurement system identifies potential problems ahead of actual failure allowing corrective action to be taken. This requires using techniques such as audits and hazard assessments. 

The critical results of a PrHA are a list of action items. Action items are written by the PrHA team any time additional effort is warranted to further analyze a specific accident scenario, eliminate the hazard, or reduce risks. Action items are not usually specific corrective actions. Rather, they alert management to potential problems that require action. Sometimes, action items suggest alternatives or recommend safety improvements. However, if a problem is simple, if a PrHA team is quite experienced, or if there is only one solution, an action item may recommend a specific corrective action. 

All action items are presented to management for review and evaluation, and for determination of what, if any, corrective actions should be taken to eliminate hazards or reduce risks. Because many action items may be generated during a PrHA, the team may choose to rank the items according to the probability of occurrence and/or the severity of the consequences of their corresponding accident scenarios. 

Record accident/incident causes and corrective actions and other operating experience for future guidance... 

For several months before the accident, conditions at the plant had been deteriorating. Procedures were not carefully followed and several mechanical features were either shutdown or compromised. Examples include the refrigeration circuit that was depleted of coolant and the vent gas scrubber that was out of service. The temperature indicator on one tank was defective. The temperature in one of the tanks had been allowed to exceed the maximum limit by as much as 15°C with no corrective action. 

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). 

FOQA and other such voluntary reporting programs allow early identification of trends and changes in behavior (i.e., migration of systems toward states of increasing risk) before they lead to accidents. Follow-up is provided to ensure that unsafe conditions are effectively remediated by corrective actions. 

Incident and accident investigation reports and corrective actions taken... 

In one case the team determined that an injury accident had been caused, in part, by a block valve being left in the closed position when it should have been open. The company had many other similar facilities. Therefore, two members of the investigation team toured those sites to ensure that the equivalent valve at those sites was open and tagged. Also, each site crew was briefed as to what had happened. Finally, on the following day, the safety manager issued a company-wide bulletin in which all managers were told of what had happened, and what immediate corrective actions to take. 

Major incidents usually require that an unusual, even bizarre, set of events take place because most of the predictable accident scenarios have already been considered, and corrective action taken. Given, therefore, that most incidents are complex and even strange, one of the most important roles of a risk management professional is to explain to the court just what happened in terms and language that they can understand. 

Accident Report—Records the findings of an accident investigation, the cause or causes of an accident, and recommendations for corrective action. 

After one of my presentations, an attendee spoke to me about the poor quality of incident investigation reports that reached her desk. I had spoken of the need to emphasize systems causal factors and to get away from the excessive concentration shown in some of their investigation reports on what the worker had done in the accident process. She said that almost all of the investigation reports that came to her desk suggested a corrective action that would improve worker behavior, and stopped there. 

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