CF Lecture 15b. Accident-Incident Investigation

7/27/2019 CF Lecture 15b. Accident-Incident Investigation

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Accident InvestigationAccident Investigation

Learning from mistakesLearning from mistakes


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Accidents

It may be that up to

95% of accidents arecaused by people


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Incident Investigation

90% of all accidents andincidents are attributable

to a companys

management. Demming.


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Definitions


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Definitions

Accident: An undesired event that

results in harm to people, damage

to property or the environment or

loss to process

Incident: An undesired event

which under differentcircumstances could have

become an accident.


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What causes an accident

or incident?


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or incident?

Someone commits anunsafe act

Something is in an unsafe

condition


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or incident?

Someone commits anunsafe act

Something is in an unsafe

condition

An Immediate Cause


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or incident?

An Immediate Cause

Conditions exist which

allow the Immediate Cause


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or incident?

An Immediate Cause

Conditions exist which

allow the Immediate Cause

A Basic Cause


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or incident?

An Immediate Cause or

Causes

A Basic Cause or Causes


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or incident?

An Immediate Cause or

Causes

A Basic Cause or Causes

Underlying Management

Failures


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The Accident Sequence

Basic Cause

Immediate Cause

Basic Cause

Basic Cause

Immediate Cause

Immediate Cause

An Accident Happens


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Immediate Cause

The circumstances which immediatelyprecede the accident

Can usually be seen or sensedOften described as Unsafe Acts or Unsafe

Conditions

They are substandard practices or

conditions

Addressing these may not preventrecurrence


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Basic Cause

The factors which allowed the ImmediateCause to exist

Not always obvious, require probingSometimes called Root, Real, Underlying

or Contributing Cause

Explain why we have substandard

performance or conditions

Must be addressed to prevent recurrence


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Immediate Causes 1

Inadequate Guards or barriers

Failure in Communication

Failure to follow rules or procedures

Inadequate warning or safety deviceFailure to observe

Failure to use warning device

Improper manual handling

Inadequate personal protective equipment


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Immediate Causes 2

Influence of alcohol or drugs

Inadequate tools or equipment

Misuse of tools or equipment

Work environmentPoor housekeeping

Inadequate access or egress

Lack of training

Lack of attention


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Basic Causes 1

External factors

Personal factors

Inadequate knowledge or skill

Inadequate physical abilityExcessive stress

Improper motivation

Inadequate supervision


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Basic Causes 2

Inadequate policy or plan

Inadequate planning or organisation

Inadequate standards or procedures

Inadequate engineering or designInadequate maintenance

Inadequate inspection

Inadequate training

Many of these are Management System Failures


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Investigation

Count Morozzo and the bakery.

Milan 1785.

First account of a flour explosion.

It is therefore of great importance thatthese facts should be universally known,

that public utility may reap from them

every advantage


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Investigation


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Investigation

3 Main Questions:

What happened?Why did it happen?

How do we stop it

happening again?


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Investigation

Keep asking the question Why?

Note all the answers.

Put the answers into a logical

sequence.

Test the theory against theevidence.


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Why did the sub drop?

The chain came unhooked.

Why was that? The hook has a safety catch.


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The catch failed.

Why?

The hook was upside down.

Why was that?

Because the hook was looped through the

lifting eye and hooked back round itself.


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Why did he do it l ike that?

The hook was not big enough to go over the lifting eye on the

sub.

Why?

The chain hoist was designed for a smaller lifting eye.

Why did he use it then?

It was left there from a previous job with a smaller sub. Itwould have meant getting a larger hoist from the rigging loft

and he was only going to be a few minutes inspecting the

sub


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Steps in Investigation

Respond to the incident promptly

Gather all the pertinent information

Analyse the incident and determineimmediate and basic causes

Review the findings to ensure they fit theevidence

Prepare a report


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Steps in Investigation

Review the report with those involved

Assist in developing corrective actions

Ensure an action plan is drawn upMonitor the action plan to ensure

completion

As appropriate, share the experience and

lessons learned


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Investigation tools

Various proprietary packages are available:

TopSet

TapRoot

Tripod (Bow tie method)

Investigator

These guide you through a process, and ensureyou dont miss items. However you can do justas good a job with basic tools, by making sureyou are methodical and consistent.


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Bow tie diagram


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Communication after the

Investigation

Communicate to as wide an audience aspossible

Dont just think of your own operation, aslight variation in circumstances maymake the same incident possibleelsewhere

Learn from the incident


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B C Water jet accident

CF Lecture 15b. Accident-Incident Investigation

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Transcript of CF Lecture 15b. Accident-Incident Investigation