Accidents documentation

In design it is typical that the same mistakes are done again since the use of available information is not organized. The use of case-based reasoning enhances the reuse of available experience, which reduces the possibility that the same errors are done more than once. In this work CBR was used for the evaluation of the inherent safety of process structure. The casebase was collected from design standards, accident documents and good engineering practice. 

Safety, patient safety, sentinel event, medical accident, near miss, good catch, Office of Patient Safety, JCAHO, focused event analysis, disclosure, peer review, confidentiality, maltreatment of minors, root cause analysis, patient safety report, accident, documentation... 

Chlorine was the second most frequently involved chemical in accidents documented for the RMP Info database " (see Table 2.1). For example, in 2005, a switch error caused a 42-car train to collide with another parked train in South Carolina, puncturing a tank car full of chlorine. As a result of exposure to chlorine, nine people died 250 were sent to the hospital and 5400 people had to be evacuated from the surrounding area. Its abundance and affordability makes it an attractive agent for terrorists. 

Tknhydrous ammonia was the number one most frequently involved chemical in accidents documented for the RMP Info database (see Table 2.1). 

Gather prior accident documentation and develop plan of action and approach methodology. 

It is obvious that incidents like pipeline leakage occur more frequently than has been reported. This report contains accidents with consequences being injuries, fatalities, or damage to property, while accident documentation should also include incidents or near-misses without major consequences. Unlike accidents with significant material or personal damage, near misses and smaller incidents are much harder to discover, even though they may be caused by the same conditions and therefore be represented by exactly the same scenarios. Identifying specific holes in barriers requires more details of input rather than was usually reported here. 

The models developed here can be informed using available databases of occupational accidents documented in the industries. Sufficient statistics to use the models include only the number of workdays, the workdays loss due to recovering from occupational accidents, and the number of occupational accidents over the period of observation for each worker. 

Contracts or associated documents normally specify that the toller will report accidents, incidents, releases and agency inspections to the client as soon as practicable or within a specified time frame. This is particularly important if these involve injuries, offsite consequences, or damage to property resulting from work performed for the client. The toller should also be requested to provide their client with copies of any reports sent to regulatoiy agencies for these occurrences. 

Contract documents should be reviewed. The HASP should reflect and possibly reference contractual agreements. Contract documents can contain much information pertinent to site safety. For example, many contracts contain monetary incentives for completion of site work accident free. If management wishes to share some of this monetary incentive with site workers, the HASP is an excellent vehicle for communicating safety incentive programs. 

The results of a What-If/Checklist analysis are documented like the results of a What-lf analysis as a table of accident scenarios, consequences, safety levels, and action items. The results may also include a completed checklist or a narrative. The PrHA team may also document the completion of the checklist to illustrate its completeness. The PSM rule requires detailed... 

A risk assessment analyses systems at two levels. The first level defines the functions the system must perform to respond successfully to an accident. The second level identifies the hardware for the systems use. The hardware identification (in the top event statement) describes minimum system operability and system boundaries (interfaces). Experience shows that the interfaces between a frontline system and its support systems are important to the system cs aluaiion and require a formal search to document the interactions. Such is facilitated by a failure modes and effect analysis (FMEA). Table S.4.4-2 is an example of an interaction FMEA for the interlace and support requirements for system operation. 

Brown, D. F., W. E. Dunn, and M. A. Lazaro, 1997a, CASRAM The Chemical Accident Stochastic Risk Assessment Model Technical Documentation, BetaVersion 0.8, ANL,... 

Lazaro, M. A. et al, 1997, Model Review and Evaluation for Application in DE Safety Basis Documentation of Chemical Accidents Modeling Guidance for Atmospheric Dispersion and Consequence Assessment, ANL/EAD/TM-75, September. 

Selection of incidents described was based on the availability of information, the kind and amount of material involved, and severity of damage. Accidents occurring on public property generally produce better published documentation than those occurring on privately owned property. 

This is partly because the traditional approach is well known and documented in the industry, whereas the other approaches have received very little application to date. In addition, despite the successes of the traditional approach in the area of occupational safety, it may be less applicable in areas such as the prevention of major chemical accidents. 

Documents such as job descriptions, operating manuals, emergency procedures, accident, and "near-accident" records, can be useful sources of information about the task to be studied. Pipework and instrumentation diagrams can also be used to gain an insight into the complexity of the process, the type of control loops installed, and the process parameters to be manually controlled by the workers. 

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. 

The DS team spent one session compiling a list of the documentation requirements that they were aware of from their individual experiences. This documentation ranged from vessel details and drawings to accident/incident reporting to MSDSs to safety procedures. Many different departments and functions were involved. Some documentation was kept in hard copy form, while the rest was in electronic form but on several different systems. The... 

In April 1982, a data workshop was held to evaluate, discuss, and critique data in order to establish a consensus generic data set for the USNRC-RES National Reliability Evaluation Program (NREP). The data set contains component failure rates and probability estimates for loss of coolant accidents, transients, loss of offsite power events, and human errors that could be applied consistently across the nuclear power industry as screening values for initial identification of dominant accident sequences in PRAs. This data set was used in the development of guidance documents for the performance of PRAs. 

This report documents the development of data on the severity as well as the frequency of accidents involving truck, rail, and air transport. Volume 1 includes a summary giving the probability of occurrence of accidents as a function of accident severity. Subsequent Volumes give supporting data, calculations and analysis. 

An occurrence involving equipment performance or human action, or an occurrence external to die system tliat causes system upset. In this document an event is associated with an accident either as the cause or a contributing cause of die accident or as a response to die accident-inidating event. 

All surveyors need a database of technical information, which should include reports of accidents or of defects that could lead to accidents derived from other sources. He also needs a regular supply of technical documentation from his head office that keeps him abreast of technical developments. If his company operates an effective quality assurance system, they will periodically check that he is keeping these data properly and they may control the indexing of them. 

Many accidents occur because the operator or maintenance person does not understand the hazards involved or has not been instructed on the precautions to be taken. The policy document should identify the main hazards within the company with advice on which rules must be obeyed while carrying out a hazardous task. General rules should also be included to cover items such as untidy work areas, replacement of guards, the use of protective cloth-ing/equipment where appropriate, safe working practices in handling goods and materials, etc. It is essential that on the introduction of new products, processes, operations or plant and equipment that any hazards associated with these are brought to the attention of all concerned. 

Hazard An inherent physical or chemical characteristic that has the potential for causing harm to people, property, or the environment. In this document, it is the combination of hazardous material, an operating environment, and certain unplanned events that could result in an accident. 

Acute biological effects of the Chernobyl accident on local natural resources were documented by Sokolov et al. (1990). They concluded that the most sensitive ecosystems affected at Chernobyl were the soil fauna and pine forest communities and that the bulk of the terrestrial vertebrate community was not adversely affected by released ionizing radiation. Pine forests seemed to be the most sensitive ecosystem. One stand of 400 ha of Pirns silvestris died and probably received a dose of 80 to 100 Gy other stands experienced heavy mortality of 10- to 12-year-old trees and up to 95% necrotization of young shoots. These pines received an estimated dose of 8 to 10 Gy. Abnormal top shoots developed in some Pirns, and these probably received 3 to 4 Gy. In contrast, leafed trees such as birch, oak, and aspen in the Chernobyl Atomic Power Station zone survived undamaged, probably because they are about 10 times more radioresistant than pines. There was no increase in the mutation rate of the spiderwort, (Arabidopsis thaliana) a radiosensitive plant, suggesting that the dose rate was less than 0.05 Gy/h in the Chernobyl locale. 

The accident at the Chernobyl, Ukraine, nuclear reactor on April 26, 1986, contaminated much of the northern hemisphere, especially Europe, by releasing large amounts of radiocesium-137 and other radionuclides into the environment. In the immediate vicinity of Chernobyl at least 30 people died, more than 115,000 others were evacuated, and the consumption of locally produced milk and other foods was banned because of radiocontamination. The most sensitive local ecosystems were the soil fauna and pine forest communities. Elsewhere, fallout from Chernobyl measurably contaminated freshwater, marine, and terrestrial ecosystems, including flesh and milk of domestic livestock. Reindeer (Rangifer tarandus) calves in Norway showed an increasing frequency of chromosomal aberrations that seemed to correlate with cesium-137 tissue concentrations tissue concentrations, in turn, were related to cesium-137 in lichens, an efficient absorber of airborne particles containing radiocesium and the main food source of reindeer during winter. A pattern similar to that of reindeer was documented in moose (Alces) in Scandinavia. 

---