Accidents recommendations

The King s Cross report made 157 recommendations and the Clapham Junction Inquiry resulted in 93 recommendations. These covered a wide range of issues such as those addressing the immediate cause of the accident recommendations to improve the response of the railway companies staff, training, communications, and management of safety and recommendations about the role of the Railway Inspectorate. I want to focus briefly on the Clapham recommendations as it is these which are most pertinent for this study. They are particularly interesting as they are another source of information about occupational health and safety on BR and one which was contemporaneous with this study. 

Developing recommendations of how to prevent a recurrence of the accident. Recommendations should address not only the specific accident bnt also methods to control future accidents. If other safety concerns are discovered during the investigation, include recommendations of how to control or mitigate these hazards. 

Safety case regulation modelled on the Seveso directives has been developing in Australia in recent years. From about 1995 Australian offshore petroleum production has been subject to a safety case requirement, while on shore, a major federal government report in 1996 recommended that the Australian states should introduce safety case requirements for major hazard facilities (NOHSC, 1996). Little progress had been made in implementing this recommendation by the time of the accident at the Esso Longford gas plant in Victoria in 1998. A Royal Commission of inquiry into this accident recommended the implementation of a safety case regime for major hazard... 

To achieve the design objectives mentioned, the necessary design provisions and procedures (e.g. for access to the control room, maintenance of essential equipment or process sampling) should be such as to enable the plant operators to manage the situation adequately in an accident. Recommendations on how to protect site personnel under accident conditions are provided in Section 10. 

What-If Analysis. The what-if analysis is simply a brainstorming technique that asks a variety of questions related to situations that can occur. For instance, in regards to a pump, the question What if the pump stops mnning might be asked. An analysis of this situation then follows. The answer should provide a description of the resulting consequence. Recommendations then foUow, if required, on the measures taken to prevent an accident. 

Avoid the temptation to overreact after an accident and install an excessive amount of protective equipment or complex procedures which are unhkely to be followed after a few years have elapsed. Sometimes an accident occurs because the protective equipment available was not used nevertheless, the report recommends installation of more protective equipment or an accident occurs because complex procedures were not followed and the report recommends extra procedures. It would be better to find out why the original equipment was not used or the original procedures were not followed. 

Most accidents do not occur because we do not know how to prevent them but because we do not use the information that is available. The recommendations made after an accident are forgotten when the people involved have left the plant the procedures they introduced are allowed to lapse, the equipment they installed is no longer used, and the accident happens again. The following actions can prevent or reduce this loss of information. 

Follow up at regular intervals (for example, during audits) to see that the recommendations made after accidents are being followed, in design as well as operations. 

Devise better information retrieval systems so that details of past accidents, in our own and other companies, and the recommendations made afterward are more easily accessible than at present. 

Joint OSHA/EPA investigations of past accidents in tolling operations include recommendations that emphasize the importance of communication between the toller and the client. The primary ways recommended to prevent recurrence of similar events focus on a joint understanding of the basic tenets of process safety elements. 

What-if produces a table of narrative questions and answers suggesting accident scenano.s. consequences, and mitigation. Table 3.3.2-1 shows a typical What-If analysis for the Dock 8. < in the left in the line above the table is indicated the line/vessel that is being analyzed. To the right is the date and page numbers. The first row in the table contains the column headings beginning with i ie what-if question followed by the consequences, safety levels, scenario number and comments. 11C comments column may contain additional descriptive information or actions/ recommendations. 

After developing questions, the PrHA team considers each to determine possible accident effects and list safety levels for prevention, mitigation, or containing the accident. The significance of each accident is determined and safety improvements to be recommended. This is repeated for each process step or area outside of team meetings for later team review... 

Mishima, J., 1993, Recommended Values and Tedmical Bases for Airborne Relea.se Fractions (ARFs), Airborne Release Rates (ARRs), and Respirable Fractions (RFs) for Materials from Accidents in DOE Fuel Cycle, Ex-Reactor Facilities, Revision 2, Draft DOE report, April. 

Hazards analysis techniques fall in two broad categories. Some techniques focus on hazards control by assuring that the design is in compliance with a pre-existing standard practice. These techniques result from prior hazards analysis, industry standards and recommended practices, results of incident and accident evaluations or similar facilities. Other techniques are predictive in that they can be applied to new situations where such pre-existing standard practices do not exist. 

If you decide my recommendations are not right for your organization, please do not ignore the accidents I have described. Check that your procedures will prevent them, or they will happen again. 

On chemical plants and oil refineries, steam, nitrogen, compressed air. lubricating oil, and other utility systems are responsible for a disproportionately large number of accidents. Flammable oils are recognized as a hazard, but services are given less attention. If the modification to the lubricating system had been systematically studied before it was made, as recommended in Chapter 2, a larger vent could have been installed, or a pipe-break and funnel could have been installed at the inlet to the sump. 

If your employers will not let you publish an accident report under your own name, perhaps they will let you send it to a journal that will publish it anonymously, for example, the Loss Prevention Bulletin (see Recommended Reading), or perhaps they will let you publish details of the action you took as a result. This may not have the same impact as the report, but it is a lot better than nothing (see Section 8.1.5). 

The section on remedial actions is usually directed at preventing a recurrence of the specific accident which is the focus of the investigation. It often consists of a sequence of recommended actions linked to the causal categories identified in the previous section. Again, remedial actions directed at more fundamental systemic causes are rarely addressed. 

With regard to evaluating these factors, it is recommended that structured checklists be used, such as those provided by the HFAM method described in Chapter 2. These checklists provide an explicit link between the direct causal factors and management policies. Figure 2.12 shows how these checklists could be used to investigate possible procedures deficiencies, and the policies that led to the deficiencies, as part of the incident investigation. Similar checklists can be used to investigate possible culture problems (e.g., inappropriate trade-offs between safety and production) that could have been implicated in an accident. 

This study investigated risks to the public from serious accidents which could occur at the industrial facilities in this part of Essex, U.K. Results are expressed as risk to an individual and societal risk from both existing and proposed installations. Risk indices were also determined for modified versions of the facilities to quantify the risk reduction from recommendations in the report. Nine industrial plants were analyzed along with hazardous material transport by water, road, rail and pipeline. The potential toxic, fire and explosion hazards were assessed for flammable liquids, ammonia, LPG, LNG, and hydrogen fluoride (HE). The 24 appendices to the report cover various aspects of the risk analysis. These include causes and effects of unconfined... 

A suitably sized ring binder with a sturdy cover is recommended, preferably covered with plastic. This procedure manual must be kept where aU who use it will have easy access to it. More than one copy may be needed in a large laboratory. Just in case an accident should take place, an extra copy must be kept in a safe spot. For durability and protection from spills each page can be inserted in a vinyl sheet protector. No pages must ever be borrowed from the book even on a temporary basis. 

To ensure that an operation is under control may necessitate atmospheric monitoring this is summarized in Chapter 9. General safety considerations, administration and systems of work requirements, including elementary first aid, are summarized in Chapter 11. For example, the recommended strategy is to include provision for appropriate first aid procedures within the system of work before specific chemicals are brought into use to so order work practices that the risk of exposure is minimized and in the event of an accident involving any but the most trivial injuries — with no foreseeable likelihood of complications or deterioration — to seek immediate medical assistance. 

Lecturers often demonstrate the reducing property of copper by making it react with concentrated sulphuric acid (this reaction is also used to make sulphur dioxide). Apparently this reaction has given rise to several accidents and this is why it is not recommended for use in lectures. 

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