Documenting the Accident

The investigation report is the primary method for documenting the accident and the corrective action. The governing organization needs to decide what the distribution of the accident report should be. If there is a significant amount of proprietary information, then obviously it cannot be widely disseminated. However, proprietary or other sensitive information can be segregated into a separate report so that the findings and reconunendations can be dissaninated. 

It is very important that any correetive aetion be implanented as soon as feasible. Letting the accident report languish in someone s files can only lead to future problems. 

Any new safety information should be immediately incorporated into the system safety analyses and SMS. The investigation results (or summary of results) must be made available for future safety analysis. 

The deftness with which a company responds to press inquiries and public concerns is an indication to the public of what kind of corporate citizen the company is. Remember that safety sells. Be as forthcoming as possible and use your response to the accident to show your concern with always trying to provide the safest work environment and product. 

Any information used in the accident investigation should be retained. If the paper takes up too much space, then scan the information electronically. If a court case results from the accident, you will be glad that you kept all the information. 

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Drivers should not be called before the committee to discuss an accident. An accident should be evaluated solely on the facts of the case as presented in the written documentation (the accident file and the driver s written statement of appeal and documentation). 

Documenting the accident is crucial. If your carrier has accident kits with disposable cameras, you should practice the following points ... 

The third step is to document the accident. A driver should carry courtesy information cards in order to collect information from eyewitnesses. The driver should ask an eyewitness to fill out his or her name, address, and telephone number so the person can be contacted at a later time. If possible, the witness should also write a description of what he or she saw. 

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. 

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. 

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. 

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. 

The accident investigation report is written using the principles of technical documentation. Items 1-4 are objective and should not include the authors opinions. Items 5-7 appropriately contain the opinions of the authors (investigation team). This technical style allows readers to develop their own independent conclusions and recommendations. As a result of these criteria, the accident investigation report is a learning tool, which is the major purpose of the investigation. 

Review the case histories described in the booklet by Marsh McLennan,31 and document the number of accidents that occurred in refineries and in petrochemical plants. 

The difficulty in utilizing accident reports lies in the lack of accident report standards. Reports vary a lot how they document the details of the accident itself, the path to the final event, the causes, and the consequences. Still the reports can tell much experience based information which can - and should be - utilized in designing new plants. In fact a major goal in improving the design of safe... 

A very good description of the accident, originating from internal as well as external documents. Always recommendations and lessons to be learned are available. The coding has been done in an extensive way and an extended abstract is available. 

The EPA RMP regulation and the European Community s Seveso II directive both exempt covered processes from some regulatory provisions, if the facility documents the absence of catastrophic damage from process accidents under reasonable worst case conditions. The State of New Jersey is also considering similar action in its proposed revisions of the Toxic Catastrophe Prevention Act (TCPA) regulations. 

For Cases I and II above, the furnaces were located in the United States. In the 1960s, a severe explosion in Great Britain was partially documented. Apparently the furnace was similar to the one noted in Case I, but argon at about 0.25 bar was used. The bottom cooling plate in the crucible failed and water was allowed to enter. No mention is made of a second event in the accident report. The incident is described as follows ... 

The information in this book came from a number of sources including stories from my experiences in the now defunct Louisiana Loss Prevention Association students in the AIChE s Chemical Plant Accidents course members of the Lake Area Industries— McNeese State University Engineering Departments OSHA Support meetings coworkers, friends, and the literature. I believe the case history stories are true, but some are hearsay and are not supported with any documentation. The approaches and... 

Standard operating procedures serve several purposes. Foremost, they require that the process be thoroughly planned, all known safety procedures be incorporated, and the operation made as independant as possible of personnel changes. In the event of an incident they aid in pinpointing the step responsible for the accident (i.e. it helps identify the unsafe act). In the event of injury or loss of equipment, it serves as a legal document to show that all known precautions were employed. It serves as a teaching aid for new employees. 

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

The PHN manager should brief area hospitals to prepare them for walk-in patients not seen at the accident site. Limited nursing documentation need be maintained for this activity. 

A cancer registry was initiated by the Indian Council of Medical Research (ICMR) in 1986. However, no conclusive evidence of an increase in cancer in the exposed population has been documented. Dikshit and Kanhere (1999) analyzed the incidence of cancer in gas-exposed males during1987-1992 but found no significant increase in cancer. On the other hand, these researchers (Dikshit and Kanhere, 1999) predicted that a true estimate of any increase in the incidence of cancer can only be made 15-20 years after the accident, but no such study has since been pubhshed. 

Failure to warn patients not only subjects optometrists to claims for injuries suffered by patients, it can also widen liability to include third parties who may be injured by patients (e.g., in an automobile accident). Optometrists should routinely document the warnings given to patients rather than relying on patients memory after the fact. ... 

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