What Causes Incidents

There are many questions that we must ask when we are trying to determine incident causes. Some people will say that acts of God  

K we work at reducing and eliminating all of the possible exposures and work errors that we face in our daily routines, we can reduce the cause of incidents. We can identify and/or anticipate possible equipment hazards [2]. 

One author uses a simple quiz for awareness training sessions to show that individuals are not aware of what is going on around them and that this is why incidents occur. The quiz is simple and illustrates a point for every one of us who drives a vehicle. We see this road sign every day but 

Developing an Effective Safety Culture A Leadership Approach 

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Sulphuric acid at 93% was added to p-nitrotoluene. The temperature reached 160°C due to a failure of the thermal control system. The sulphonic acid formed decomposed violently at this temperature. The post-accident investigation showed that the decomposition started between 160 and 190 C. In fourteen minutes the temperature rose to 190-224°C and in one minute and thirty seconds to 224-270°C. A large volume of gas was then released during the eruption. The phenomena caused by the decomposition of nitrated derivatives in the presence of sulphuric acid will be addressed several times. What these incidents have in common is the formation of large carbonised volumes. This phenomenon is common with sulphonic acids. The nitro group role is to destabilise intermediate compounds and final compounds and to generate... 

Once the evidence has heen collected and a timeline or sequence diagram developed, the next phase of the investigation involves identifying the causal factors. These causal factors are the negative occurrences and actions that made a major contrihution to the incident. Causal factors involve human errors and equipment failures that led to the incident, hut can also he undesirable conditions, failed harriers (layers of protection, such as process controls or operating procedures), and energy flows. Causal factors point to the key areas that need to he examined to determine what caused that factor to exist. 

Use print or electronic resources to find out what caused the loss of the Mars Climate Orbiter spacecraft in September 1999. How is this incident related to the Gimli Glider story Could a similar incident happen again Why or why not ... 

In addition to the OSHA 300 log, OSHA has two other documents that must be completed within the recordkeeping requirements. For each injury recorded on the OSHA 300 log, the employer is responsible for completing the OSHA 301 form. This document is commonly referred to as an incident investigation form. Here the employer will record specific information regarding the incident, such as what work the employee was performing, what occurred, and what caused the injury. OSHA... 

Information about what happened which is usually factual and has limited scope for interpretation, for example the date and time of the incident, and what caused the injury, damage or other loss. 

What causes the most confusion concerning the recognition of a near miss incident are definitions that describe an incident as some event that may or may not have caused injury. That could be anything. The American National Standards Institute, Inc. (ANSI), Standard ANSI/AIHA ZIO-2005, Occupational Health and Safety Management Systems, is one of the many definitions that cause this confusion and applying its definition of a near miss will confuse the issue more. The institute defines a near miss as an incident ... 

Failure Mode and Effects Analysis (FEMA)—FEMA is a tabulation of facility equipment items, their potential failure modes, and the effects of these failures on the equipment or facility. Failure mode is simply a description of what caused the equipment to fail. The effect is the incident, consequence, or system response to the failure. It is usually depicted in tabular format and expresses failures in an annual estimation. A FEMA is not useful for identifying combinations of failures that can lead to incidents. It may be used in conjunction with other hazard identification techniques such as HAZOP for special investigations such as critical or complex instrumentation systems. There is also a Failure Modes, Effects, and Criticality Analysis (FMECA), which is a variation of FMEA that includes a quantitative estimate of the significance of the consequence of a failure mode. 

What caused the incident Explain in detail the condition, act, or malfunction that caused the incident. Remember, it is common to have more than one reason or cause for an incident. Carelessness is not a cause. Example An employee is moving along a walkway next to a conveyor carrying rock. He steps on a stone and twists his ankle. The initial team must visualize the total picture of where the rock came from and how it ended up on the walkway. Blaming the employee for not watching where he or she was walking will lose credibility with the employee and not arrive at the root cause. 

Element 4.13 of ISO 9001 deals with specific nonconformities and element 4.14 deals with the action to eliminate their cause and prevent their recurrence. This additional ISO/TS 16949 requirement does seem to duplicate what is covered in clause 4.14.2. However, it does add a significant aspect - a reduction plan. One could be complying with elements 4.13 and 4.14 of ISO 9001 but have no reduction plan, since element 4.14 does not impose any time constraints on corrective action or require the incidence of nonconformity to be reduced. It is quite possible to take corrective action continuously and still not reduce the number of nonconformities. The requirement may be in the wrong place (i.e. in 4.13 rather than 4.14) but it is a useful addition nonetheless. 

In 1977. the technical press reported that a major leak from a 20,000-m liquefied propane tank in Qatar had ignited and that the resulting fire and explosion had killed seven people and caused extensive damage to the rest of the plant [18]. There had also been a leak the year before, but it had not ignited, and the tank had been repaired. The propane was stored at -42°C and atmospheric pressure. No detailed report on the incident was issued, for legal reasons, but a member of the company concerned published several papers [19-21], which gave new recommendations for t,he construction of tanks for refrigerated LFG, and it is thus possible to read between the lines and surmise what probably happened. 

The Chemical Process Industry (CPI) uses various quantitative and qualitative techniques to assess the reliability and risk of process equipment, process systems, and chemical manufacturing operations. These techniques identify the interactions of equipment, systems, and persons that have potentially undesirable consequences. In the case of reliability analyses, the undesirable consequences (e.g., plant shutdown, excessive downtime, or production of off-specification product) are those incidents which reduce system profitability through loss of production and increased maintenance costs. In the case of risk analyses, the primary concerns are human injuries, environmental impacts, and system damage caused by occurrence of fires, explosions, toxic material releases, and related hazards. Quantification of risk in terms of the severity of the consequences and the likelihood of occurrence provides the manager of the system with an important decisionmaking tool. By using the results of a quantitative risk analysis, we are better able to answer such questions as, Which of several candidate systems poses the least risk Are risk reduction modifications necessary and What modifications would be most effective in reducing risk ... 

Wluit is a core meltdownl What was the probable cause of the Three Mile Island incident ... 

When the cause of the incident has been established and the costs of rectification finalized, these will be compared with the insurance cover provided by the policy and the extent of the insurer s liability, if any, determined. The policy will normally be one of indemnity, i.e. returning the insured to the same position after an accident as he was before. This may be achieved by repairing or replacing what is damaged or by paying the amount of the damage. It may be necessary to carry out modifications to prevent a recurrence of the accident or desirable to up-rate the specification for better performance or the life of the machine may have been extended by the repairs carried out. In this case a degree of betterment is involved which will be reflected in the settlement by a contribution by the insured to the cost of repairs. 

My day job is as a civil service electrician for the last thirty-four years at the Veteran s Administration hospital. March 5, 2006,1 had thirty-four years with civil service. After duty at the VA hospital, all the rest is a volunteer as a firefighter, rescue worker, or helping the county sheriff and the State Highway Patrol as an interpreter. Basically, I stay pretty busy. The federal government gave us three fire vehicles after the chlorine gas incident because our old equipment was done-in by corrosion caused directly by poison chlorine gas. This gas took the paint and chrome off our fire vehicles so it was unusable for any other purpose what do you think it did to my lungs and body at the same time ... 

In the following narrative Matthew mentions an incident when he was teased about being allergic to chocolate. His mother explained to me that what had happened was that he had eaten chocolate in school, and in a reaction he had acted out so badly in class that the other students all were angry at him. His mother apologized to his classmates for his behavior and explained that it was caused by a reaction to the chocolate he had eaten. But instead of leading to forgiveness and compassion, his classmates used the information to hurt him. 

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