Finding accident repeaters

An important question in connection with accident investigations is whether the same type of accident has occurred before. This question is easily answered if a computerised accident database is available. The most efficient means of searching for similar occurrences is to utilise the free-text search facilities of the information retrieval programme. There are computerised tools for pattern recognition that may help identify accident repeaters. It is important to note that different persons may use different words to describe the same work operations, equipment, etc. There are also spelling errors and misconceptions that hinder efficient free-text search. The analyst must be well acquainted with the workplace in question and the different dialects in use. 

Example 1 There had been a truck accident at an airport. The SHE manager wanted to know whether there had been similar accidents with trucks before. He first looked in the coded field injury agent for vehicles and found two reports, one of which was relevant. Next, he made a free-text search on truck in the sequence-of-events description and found these two reports and another two reports. One of these was also relevant. 

There is a general need to query the database for accident and near-accident cases as input to decision-making. A computerised accident and near-accident database can easily help satisfy such a need. Below are some examples  

Example 1 A team on an offshore installation had performed a job-safety analysis of the entering of a tank. The safety engineer wanted to 

Example 2 The catering manager on an offshore platform was planning a first-aid course for kitchen personnel. He searched the database for accident cases illustrating the importance of first aid. 

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To others. Happiness only comes by chance when least sought, perhaps she is there. Seek, and ye shall not find ask, and ye shall not receive knock, and it shall not be opened unto yon. Happiness is always a divine accident, It is not definite quality it is the bloom of circumstances. It is useless to mix its ingredients the experiments in life which have produced it in the past may be repeated endlessly, and with infinite skill and variety—in vain. 

Occupational illness and injury187 cost 30-40 billion dollars/yr in the United States.188 In 1994 there were 6.8 million injuries and illnesses in private industry, amounting to 8.4 cases per 100 workers. Nearly two-thirds were disorders associated with repeated trauma, such as carpal tunnel syndrome.189 The Occupational Safety and Health Act of 1970 set up the National Institute Safety and Health (NIOSH) to study the problem and the Occupational Safety and Health Administration (OSHA) to deal with it through inspections and regulations. Both have received so much criticism of their effectiveness that they are struggling to find more effective ways to deal with the problem.190 NIOSH is searching for practical ways to protect workers, especially those in small businesses from methylene chloride, tetrachloroethylene, diesel exhaust in coal mines, isocyanates, 2-methoxyethanol, and others. OSHA is about to expand a plan that worked well in Maine, a state that used to have one of the worst accident and illness records in the United States.191 The 200 firms with the worst records were asked to look for deficiencies and to correct them. They were also inspected. These measures cut injuries and illnesses over a 2-year period. 

I find that what I talk about repeatedly, and I emphasize repeatedly, conveys to my staff the areas in which I mean to have snperior resnlts. They know by what I do that we are not to have employee injuries, environmental spiUs, customer complaints about product quahty, or transportation accidents. I thoronghly review every such incident. Fortunately, there haven t been many of them. 

In a repeat of a theme seen in many scientific discoveries, one of DuPont Chemical s most femous and profitable polymers was discovered by accident. Teflon, a fluo-ropolymer best known for use in cookware, is highly resistant to most solvents and acids 2ind is used in analytical chemistry in applications such as soil and acid digestion. Teflon was accidentally made for the first time by DuPont chemist Roy Plunkett in 1938. Plunkett had been working with refrigerants based on chlorofluorocarbons when he returned to the lab one momir to find a waxy solid in a container where none should have been. Thus was Teflon bom. 

One of the key findings of the initial review after the accident was that there was no formal, methodical safety risk assessment process. So the company set out to develop one. They decided that it needed to be a uniform and consistent methodology that could be used worldwide, across all product lines. Though product lines vary greatly, how their safety risks should be assessed needed to be very methodical and repeatable. Also, it was important that safety hazards and their associated risks must be communicated to the corporate level in a uniform and consistent manner so that risks could be compared across all operations. 

To simply find out what went wrong. If your reason for investigating accidents is to find out what went wrong, fix the problem, then move ahead with normal operations, you run the risk of repeat accidents... 

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