Industrial accidents investigation

Accident investigation indicates that there are often many individual causes to an accident, and that a series of incidents occur simultaneously to cause the accident. The following figure is called the safety triangle", and shows the approximate ratios of occurrence of accidents with different severities. This is based on industrial statistics. 

One of the origins of this view of error and accident causation is the theory of accident proneness, which tried to show that a small number of individuals were responsible for the majority of accidents. Despite a number of studies that have shown that there is little statistical evidence for this idea (see, e.g., Shaw and Sichel, 1971) the belief remains, particularly in traditional industries, that a relatively small number of individuals accoimt for the majority of accidents. Another element in the emphasis on individual responsibility has been the legal dimension in many major accident investigations, which has often been concerned with attributing blame to individuals from the point of view of determining compensation, rather than in identifying the possible system causes of error. 

Vernon, H. M. (1918). "An Investigation of the Factors Concerned in the Causation of Industrial Accidents." Memo Rl, Health of Munitions Workers Committee London. 

M. he investigation of accidents and near misses (that is, close calls) provides opportunities to learn how to prevent similar events in the future. Accident investigations, including detailed descriptions and recommendations, are commonly shared within the chemical industry. Many professionals believe that this sharing of information about accidents has been a major contributor to the steady improvement in safety performance. 

T. Kletz, Layered Accident Investigations, Hydrocarbon Processing (November 1979), pp. 373-382 and T. Kletz, Learning from Accidents in Industry (Boston Butterworths, 1988). 

Recommendations are the most important result of an accident investigation. They are made to prevent a recurrence of the specific accident, but they are also made to prevent similar accidents within the company and within the industry. The ultimate result of accident investigations is the elimination of the underlying causes of entire families of accidents. One good accident investigation can prevent hundreds of accidents. 

The accident investigation at Lodi, New Jersey, included previous industrial accidents with sodium hydrosulfite and aluminum. Summarize the findings of these accidents and develop a few management system recommendations for these industries. See http // www.epa.gov/ceppo/pubs/lodirecc.htm. 

Explosions shortly after the completion of vacuum distillations are common. There are two causes, firstly that the residues are unstable and, heat removal declining with the cessation of agitation and evaporation, there is unaided thermal runaway from the elevated temperature at which such distillations commonly finish. The second is that the still very hot vessel has been repressurised with air, and residues are usually combustible. Cooling of such residues should be checked, if not assisted, and air not admitted to the vessel until it is below 100°C [1], An account of the investigation of an industrial accident of the first type is available [2],... 

Bulkley, W. L. Technical Investigation of Major Process-Industry Accidents. New York AIChE Loss Prevention Series 0823. 

Absorption, Distribution, Metabolism, and Excretion. Quantitative data on the absorption of radium after intake via any exposure route are very limited. No data were located on the absorption of radium after dermal exposure. Information on laboratory workers exposed to radium during an industrial accident indicates that absorption can occur via the inhalation route. A study in elderly human subjects indicated that at least 20% of the ingested radium-224 in mock radium dial paint was absorbed and retained. No studies were located on the absorption of radium by animals after inhalation or dermal exposure. A study of orally exposed rats indicated that retention of radium at 400 to 500 days was 1% to 7% of the administered dose. Further studies to investigate the absorption and retention of radium after inhalation, oral, and dermal exposure would be helpful in elucidating the relative risks associated with exposure by each route. 

Trevor Kletz often described accident investigation with the story of peeling an onion. In the opening paragraph of Learning from Accidents in Industry, [6] Kletz states ... 

Polyethylene (also known as polythene) was synthesized by accident in 1932 when scientists at Imperial Chemical Industries (ICI) investigated the reaction between ethylene and various compounds at high pressure. Polyethylene is generally commercially polymerized from monomer ethylene gas under high pressure (1000—3000 atmospheres) and at temperatures of 80-300°C (Brydson, 1999). A free radical initiator such as benzoyl peroxide, azodi-isobutyronitrile or oxygen is added. The reaction is exothermic and must be cooled to control the rate of polymerization and molecular weight. 

Improve the accident investigation philosophy The philosophy and aim orientation of the accident investigation shall focus on improvement of safety and avoidance of accidents, analysis of the radical causes of the accidents, and learning of experiences and lessons. These measures serve as the important grounds for relevant department, industry and enterprise to formulate standards. Their implementation is supervised and tracked, so as to avoid reoccurrence of similar accidents. 

Farrell, K.V., 2008. Investigation Process for Industrial Accident Scenes. Mary Kay Process Safety Center. 

Investigations of industrial accidents reveal that most are caused by human error. The twentieth century s worst industrial disasters—Bhopal, Three Mile Island, and Chernobyl—helped clarify the complex chain of system problems that lead to human error. System problems are problems caused by a process system with built in design and operating deficiencies. The accidents provided numerous checklists and case studies for control room and equipment design. A partial list of some of the problems found at the industrial sites mentioned above are ... 

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