Report of Investigation

Results of the investigation, including the identification of the root causes and the preventive/corrective actions, should be shared with all employees in the workplace who are affected by the findings. 

C iange Analysis looks at a problem by analyzing the devkatiori between whet ie expected and what actually happened The evaluator e Mntiariy asks what differences occurred to make the outcome of this task or actfvity different from all the other times thk task or activity was successfully compleied 

This technique consists of asking the questions What When Where Who How Answering these questions should provide direction toward answering the root cause determination question Why  

Primary and secondary questions included within each category will provide the prompting r ecessary to thoroughly answer the overall t esdon. Some of Ihe questions will not be applicable to any given condition Some amount of redundancy exists in the questions to ensure that all items are addressed. 

The following outline can be useful in developing the information to be included in the incident report  

As noted earlier, an accident investigation is not complete until a report is prepared and submitted to proper aumorities. Special report forms are available in many cases. Omer instances may require a more extended report. Such reports are often very elaborate and may include a cover page, a title page, an abstract, a table of contents, a commentary or narrative section, a discussion of probable causes, and a section on conclusions and recommendations. The following outline has been found especially useful in developing the information to be included in me formal report  

Account of the accident (what happened) a. Sequence of events 

Recommendations (to prevent a recurrence) for immediate and long-range action to remedy 

Accident investigation should be an integral part of your written safety and health program. It should be a formal procedure. A successful accident investigation determines not only what happened, but also finds how and why the accident occurred. Investigations are an effort to prevent a similar or perhaps more disastrous sequence of events. You can then use the resulting information and recommendations to prevent future accidents. 

Once the hazards have been identified then the information and sources must be analyzed to determine their origin and the potential to remove or mitigate their effects on the workplace. Analysis of hazards forces us to take a serious look at them. 

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M. Jacobson, A. R. Cooper, andj. Nagy, Explosivity of Metal Powders, U.S. Bureau of Miaes, Report of Investigations 6516, Washiagton, D.C., 1964. 

G. W. Eiger, Preparation and Chlorination of Titanium Carbide from Domestic Titaniferous Ores, Report of Investigation 8497, U.S. Department of Interior, Bureau of Mines, Washington, D.C., 1980. 

H. A. Leverin, Industrial Waters of Canada—Report of Investigations 1934 to 1940, Bureau of Mines Report 807, Canada Department of Mines and Resources, Ottawa, Ont., 1942. 

R. H. Spmte and D. J. Kelsh, E/ectrokinetic Densif cation of So/ids in a Coa/Mine Sediment Pond—A Feasibi/ity Study, Bureau of Mines Report of Investigations 9137, 1988. 

Physical Properties The free-swelling index (FSl) measures the tendency of a coal to swell when burned or gasified in fixed or fluidized beds. Coals with a high FSl (greater than 4) can usually be expected to cause difficulties in such beds. Detads of the test are given by the ASTM D 720 (American Society for Testing and Materials, op. cit.) and U.S. Bureau of Mines Report of Investigations 3989. 

Jones, G. W. and Kennedy, R. E.. Limits of Inflammability of Natural Gases Containing High Percentages of Carbon Dioxide and Nitrogen, Bureau of Mines Report of Investigation, 3216, 1933. 

FRS. 1985. Evaluation of the Performance of an End-of-Line Flame Arrester When Subjected to Unconfmed Hydrogen-Air Explosions. Report of Investigation FRD 184/03 for IMl Amal Limited. Fire Research Station, Borehamwood, Herts., England. 

Grumer, J., Harris, M. E., and Rowe, V. R. 1956. Lundamental Llashbaek, Blowoff and Yellow-Tip Limits ofPuel Gas-Air Mixtures. U.S. Bureau of Mines Report of Investigations 5225 (July 1956). 

Burgess, D. S., and M. G. Zabetakis. 1973. Detonation of a flammable cloud following a propane pipeline break. The December 9,1970, Explosion in Port Hudson, Mo. Bureau of Mines Report of Investigations No. 7752. 

Acherman, W. L., Carter, J. P., Kenahan, C. B. and Schlan, D., Corrosion Properties of Molybdenum, Tungsten, Vanadium and some Vanadium Alloys, Report of Investigations No. 6 715, US Bureau of Mines (1966)... 

Babitzke, H. R., Siemens, R. E., Asai, G. and Kato, H., Development of Columbium and Tantalum Alloys for Elevated-Temperature Service, Bureau of Mines Report of Investigations 6SSS, US Department of the Interior, (1964)... 

It was used as a commercial blasting expl Ref C.E, Munroe S.P. Howell, Report of Investigation, Bur of Mines (June 1920) CA14, 2708(1920)... 

Report of investigations No. 83. Austin, Bureau of Economic Geology, University of Texas. Livingstone, H.G., Payne, WJ.A. and Friend, M.T 1962 Urea excretion in ruminants. Nature 194 1057-1058. 

Reference value A value reported on an SRM Certificate of Analysis and/or a Reference Material (RM) Report of Investigation that represents the best estimate of the true value where all known or suspected sources of bias have not been fully investigated by NIST. The value has an associated uncertainty that may not include all sources of uncertainty and may represent only a measure of the precision of the measurement method(s). 

Hiteshue, R.W., Friedman, S., Madden, R. United States Bureau of Mines, Report of Investigations, 6125, 1962. 

Dallimore P.J. and R.F. Holub, General Time-Dependent Solutions for Radon Diffusion from Samples Containing Radium, Report of Investigation 8765, Bureau of Mines, United States Department of the Interior, Denver (1982). 

Gasior, S.J. et al., Production of synthesis gas and hydrogen by the steam iron process—Pilot-plant study of fluidized and free-falling beds, Bureau of Mines Report of Investigations, Pittsburgh, PA, 5911,49,1961. 

Katell, S., Faber, J.H., and Wellman, P.,An Economic Evaluation of Hydrogen Production by the Continuous Steam-Iron Process at Seven Atmospheres, Bureau of Mines Report of Investigations (No. 6089), Pittsburgh, PA, 13,1962. 

Hummer, John J., John M. Googin, Ph.D, Michael W. Knazovich, Paul R. Wasilko, and Janice West, 1992. "Report of Investigation of Accidental Release of Hydrogen Fluoride from the Y-12 Plant Oak Ridge, Tennessee, January 24, 1992," Martin Marietta Energy Systems, Inc., Oak Ridge, TN, March 1992. 

Kuchta, J. M., A. L. Fumo, and A. C. Imhof, "Classification Test Methods foir Oxidizing Materials," U. S. Bureau of Mines, Report of Investigation 7594 (1972). 

Bulatovic, S.M., An Investigation of the Recover of Copper and Gold from Igarape Bahia Oxide Copper-Gold Ores, Report of Investigation LR4533, 1997. 

Morrice, E., Valkiewicz, J.W., and Casale, G., Pilot Plant Flotation of Serpentinized Platinum-Palladium Ore from Stillwater Complex, Report of Investigation 8885, 1976. 

Bulatovic, S., and Newman, D., The recovery of Copper/Nickel and PGM from Strathcona Plant, Report of Investigation LR3958, 1984. 

Bulatovic, S., and Jessup, T., An Investigation of Alternative Reagent Schemes in Treatment of High Chromium PGM Ores, Report of Investigation LR00099-274, 2006. 

Bulatovic, S., Bigg, A.C.T., and Yen, T., Laboratory Development Testwork on Kolwezi and Komoto Oxide and Mixed Copper Cobalt Ores, Report of Investigation No. 3, 1979. 

Bulatovic, S., Development of Reagent Scheme for Beneficiation ofNachanga (Zambia) Open Pit Oxide Ore, Report of Investigation LR5635, pp. 20-156, 1993. 

Bulatovic, S., Process Development for Treatment of Pb/Zn of Oxide Sulphide Ore from Prairie Creek (Canada), Report of Investigation, January 2006. 

Bulatovic, S., Process Developmentfor Beneficiation of Oxide Lead, Silver, Gold OreforMinera Corona, Peru, SBM Report of Investigation, May 2007. 

Bulatovic, S.M., New Collector Mixture for Tin Flotation - The Recovery of Tin from San Rafael Gravity Tailings, Report of Investigation, 2005, p. 262. 

Bulatovic, S., Development Testwork on Tin Recovery for Huanuni Fines, Report of Investigation, 2002, p. 260. 

Bulatovic, S., Research and Development of Niobium Flotation from Pegmatite Ore, SGS Report of Investigation, 2007. 

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