Discover how you should be running you Health and Safety incident investigations. This best practice guide covers the key elements of effective investigations into accidents and incidents that occur at work.
OSHA and National Safety Council - What is a Near Miss?Garrett Foley
The Alliance Safety Program, started by OSHA and the National Safety Council, strives to educate employers and employees about near misses and their key benefits to overall safety.
CHAPTER15 Leaming from Accidents While no company want.docxmccormicknadine86
CHAPTER15
Leaming from Accidents
While no company wants to have accidents, once they occur, it is
important to learn from these accidents. One of the worst mistakes to make
for a company is to repeat an accident. Accidents are opportunities to fix the
safety program, correct hazardous situations, train employees on the correct
behavior, and ensure systemic problems are corrected. While an accident is
dreadful, we must learn from them.
The key concept of a safety program and the accident investigation program
15 ro prevent accidents and/ or prevent recurrence of an accident. No one
wants to get hurt, but actions/inactions and conditions will dictate an accident.
All 'd aca ents are caused, and there are many consequences of accidents. The
heallh and safety of personnel is the utmost priority, but other issues include
funcuonal c bili' f · fin · al 11 bein apa ty a ter los s, public image and reputation, anc1 we -
g 0oss of sales), and also civil or criminal legal action.
Lessons Learned
"If it ca 0 happen h ' 1 " Thi · the co at t 1s ocation then it can happen anywhere. s 1s
ncept of 1 ' essons learned. One of the most important elements of
159
Parl IV: Pmornting Arddmls
160
accident in vcs t.igat.ion that ha s been discussed is to fi
an . . gure Out Wh
happened and how to prevent It. One of the bigge st mistakes of an . at
. k d kin y acc1de is not learning from your rrusta ·e s an ma · g the same mist k . nt
. h aeagainAu companies need to not 1us1 fix t e problem areas and prev ·
' ent recurren
b)' correcting the problems, but actually develop a system to lea f ce
. rn rorn th
accidents. A lesso ns learned program will ensure that accidents a e
, . . re corrected
not just at o ne locat1on, but at all locations. Also a lessons lea d f
. . rne rorn a
smaller accident can hdp avoid a larger accident from happening. "If ~-e
were really good at learrung from o ur mistakes, two similar accidents would
never occur" Qanson 2009) .
One of the biggest failures of companies is not communicating the
problems, causes , issues, rrustakes, and / or failures of an accident to the other
divisions of the company. If a company has multiple locations, then these
issues could cause an accident anywhere. Communication is the key. Luckily,
communication is much easier now, and accident information can be e-mailed
immediately to other off-s ite locations.
There are many different ways to disseminate lessons learned information,
and many companies e-mail out each cause and corrective actions to all.
Others put together a weekly or monthly newsletter to disseminate the
accident information. Communication is the key component.
Review Board
Another important aspect is to have an accident review board to review
the accide nt report to check for quality, consistency, and ensure the faccs ,
causal factors, and corrective actio n s are correct. There are many types
of re view board s. The be st review bo ...
CHAPTER15 Leaming from Accidents While no company want.docxspoonerneddy
CHAPTER15
Leaming from Accidents
While no company wants to have accidents, once they occur, it is
important to learn from these accidents. One of the worst mistakes to make
for a company is to repeat an accident. Accidents are opportunities to fix the
safety program, correct hazardous situations, train employees on the correct
behavior, and ensure systemic problems are corrected. While an accident is
dreadful, we must learn from them.
The key concept of a safety program and the accident investigation program
15 ro prevent accidents and/ or prevent recurrence of an accident. No one
wants to get hurt, but actions/inactions and conditions will dictate an accident.
All 'd aca ents are caused, and there are many consequences of accidents. The
heallh and safety of personnel is the utmost priority, but other issues include
funcuonal c bili' f · fin · al 11 bein apa ty a ter los s, public image and reputation, anc1 we -
g 0oss of sales), and also civil or criminal legal action.
Lessons Learned
"If it ca 0 happen h ' 1 " Thi · the co at t 1s ocation then it can happen anywhere. s 1s
ncept of 1 ' essons learned. One of the most important elements of
159
Parl IV: Pmornting Arddmls
160
accident in vcs t.igat.ion that ha s been discussed is to fi
an . . gure Out Wh
happened and how to prevent It. One of the bigge st mistakes of an . at
. k d kin y acc1de is not learning from your rrusta ·e s an ma · g the same mist k . nt
. h aeagainAu companies need to not 1us1 fix t e problem areas and prev ·
' ent recurren
b)' correcting the problems, but actually develop a system to lea f ce
. rn rorn th
accidents. A lesso ns learned program will ensure that accidents a e
, . . re corrected
not just at o ne locat1on, but at all locations. Also a lessons lea d f
. . rne rorn a
smaller accident can hdp avoid a larger accident from happening. "If ~-e
were really good at learrung from o ur mistakes, two similar accidents would
never occur" Qanson 2009) .
One of the biggest failures of companies is not communicating the
problems, causes , issues, rrustakes, and / or failures of an accident to the other
divisions of the company. If a company has multiple locations, then these
issues could cause an accident anywhere. Communication is the key. Luckily,
communication is much easier now, and accident information can be e-mailed
immediately to other off-s ite locations.
There are many different ways to disseminate lessons learned information,
and many companies e-mail out each cause and corrective actions to all.
Others put together a weekly or monthly newsletter to disseminate the
accident information. Communication is the key component.
Review Board
Another important aspect is to have an accident review board to review
the accide nt report to check for quality, consistency, and ensure the faccs ,
causal factors, and corrective actio n s are correct. There are many types
of re view board s. The be st review bo.
Discover how you should be running you Health and Safety incident investigations. This best practice guide covers the key elements of effective investigations into accidents and incidents that occur at work.
OSHA and National Safety Council - What is a Near Miss?Garrett Foley
The Alliance Safety Program, started by OSHA and the National Safety Council, strives to educate employers and employees about near misses and their key benefits to overall safety.
CHAPTER15 Leaming from Accidents While no company want.docxmccormicknadine86
CHAPTER15
Leaming from Accidents
While no company wants to have accidents, once they occur, it is
important to learn from these accidents. One of the worst mistakes to make
for a company is to repeat an accident. Accidents are opportunities to fix the
safety program, correct hazardous situations, train employees on the correct
behavior, and ensure systemic problems are corrected. While an accident is
dreadful, we must learn from them.
The key concept of a safety program and the accident investigation program
15 ro prevent accidents and/ or prevent recurrence of an accident. No one
wants to get hurt, but actions/inactions and conditions will dictate an accident.
All 'd aca ents are caused, and there are many consequences of accidents. The
heallh and safety of personnel is the utmost priority, but other issues include
funcuonal c bili' f · fin · al 11 bein apa ty a ter los s, public image and reputation, anc1 we -
g 0oss of sales), and also civil or criminal legal action.
Lessons Learned
"If it ca 0 happen h ' 1 " Thi · the co at t 1s ocation then it can happen anywhere. s 1s
ncept of 1 ' essons learned. One of the most important elements of
159
Parl IV: Pmornting Arddmls
160
accident in vcs t.igat.ion that ha s been discussed is to fi
an . . gure Out Wh
happened and how to prevent It. One of the bigge st mistakes of an . at
. k d kin y acc1de is not learning from your rrusta ·e s an ma · g the same mist k . nt
. h aeagainAu companies need to not 1us1 fix t e problem areas and prev ·
' ent recurren
b)' correcting the problems, but actually develop a system to lea f ce
. rn rorn th
accidents. A lesso ns learned program will ensure that accidents a e
, . . re corrected
not just at o ne locat1on, but at all locations. Also a lessons lea d f
. . rne rorn a
smaller accident can hdp avoid a larger accident from happening. "If ~-e
were really good at learrung from o ur mistakes, two similar accidents would
never occur" Qanson 2009) .
One of the biggest failures of companies is not communicating the
problems, causes , issues, rrustakes, and / or failures of an accident to the other
divisions of the company. If a company has multiple locations, then these
issues could cause an accident anywhere. Communication is the key. Luckily,
communication is much easier now, and accident information can be e-mailed
immediately to other off-s ite locations.
There are many different ways to disseminate lessons learned information,
and many companies e-mail out each cause and corrective actions to all.
Others put together a weekly or monthly newsletter to disseminate the
accident information. Communication is the key component.
Review Board
Another important aspect is to have an accident review board to review
the accide nt report to check for quality, consistency, and ensure the faccs ,
causal factors, and corrective actio n s are correct. There are many types
of re view board s. The be st review bo ...
CHAPTER15 Leaming from Accidents While no company want.docxspoonerneddy
CHAPTER15
Leaming from Accidents
While no company wants to have accidents, once they occur, it is
important to learn from these accidents. One of the worst mistakes to make
for a company is to repeat an accident. Accidents are opportunities to fix the
safety program, correct hazardous situations, train employees on the correct
behavior, and ensure systemic problems are corrected. While an accident is
dreadful, we must learn from them.
The key concept of a safety program and the accident investigation program
15 ro prevent accidents and/ or prevent recurrence of an accident. No one
wants to get hurt, but actions/inactions and conditions will dictate an accident.
All 'd aca ents are caused, and there are many consequences of accidents. The
heallh and safety of personnel is the utmost priority, but other issues include
funcuonal c bili' f · fin · al 11 bein apa ty a ter los s, public image and reputation, anc1 we -
g 0oss of sales), and also civil or criminal legal action.
Lessons Learned
"If it ca 0 happen h ' 1 " Thi · the co at t 1s ocation then it can happen anywhere. s 1s
ncept of 1 ' essons learned. One of the most important elements of
159
Parl IV: Pmornting Arddmls
160
accident in vcs t.igat.ion that ha s been discussed is to fi
an . . gure Out Wh
happened and how to prevent It. One of the bigge st mistakes of an . at
. k d kin y acc1de is not learning from your rrusta ·e s an ma · g the same mist k . nt
. h aeagainAu companies need to not 1us1 fix t e problem areas and prev ·
' ent recurren
b)' correcting the problems, but actually develop a system to lea f ce
. rn rorn th
accidents. A lesso ns learned program will ensure that accidents a e
, . . re corrected
not just at o ne locat1on, but at all locations. Also a lessons lea d f
. . rne rorn a
smaller accident can hdp avoid a larger accident from happening. "If ~-e
were really good at learrung from o ur mistakes, two similar accidents would
never occur" Qanson 2009) .
One of the biggest failures of companies is not communicating the
problems, causes , issues, rrustakes, and / or failures of an accident to the other
divisions of the company. If a company has multiple locations, then these
issues could cause an accident anywhere. Communication is the key. Luckily,
communication is much easier now, and accident information can be e-mailed
immediately to other off-s ite locations.
There are many different ways to disseminate lessons learned information,
and many companies e-mail out each cause and corrective actions to all.
Others put together a weekly or monthly newsletter to disseminate the
accident information. Communication is the key component.
Review Board
Another important aspect is to have an accident review board to review
the accide nt report to check for quality, consistency, and ensure the faccs ,
causal factors, and corrective actio n s are correct. There are many types
of re view board s. The be st review bo.
Hierarchical Digital Twin of a Naval Power SystemKerry Sado
A hierarchical digital twin of a Naval DC power system has been developed and experimentally verified. Similar to other state-of-the-art digital twins, this technology creates a digital replica of the physical system executed in real-time or faster, which can modify hardware controls. However, its advantage stems from distributing computational efforts by utilizing a hierarchical structure composed of lower-level digital twin blocks and a higher-level system digital twin. Each digital twin block is associated with a physical subsystem of the hardware and communicates with a singular system digital twin, which creates a system-level response. By extracting information from each level of the hierarchy, power system controls of the hardware were reconfigured autonomously. This hierarchical digital twin development offers several advantages over other digital twins, particularly in the field of naval power systems. The hierarchical structure allows for greater computational efficiency and scalability while the ability to autonomously reconfigure hardware controls offers increased flexibility and responsiveness. The hierarchical decomposition and models utilized were well aligned with the physical twin, as indicated by the maximum deviations between the developed digital twin hierarchy and the hardware.
About
Indigenized remote control interface card suitable for MAFI system CCR equipment. Compatible for IDM8000 CCR. Backplane mounted serial and TCP/Ethernet communication module for CCR remote access. IDM 8000 CCR remote control on serial and TCP protocol.
• Remote control: Parallel or serial interface.
• Compatible with MAFI CCR system.
• Compatible with IDM8000 CCR.
• Compatible with Backplane mount serial communication.
• Compatible with commercial and Defence aviation CCR system.
• Remote control system for accessing CCR and allied system over serial or TCP.
• Indigenized local Support/presence in India.
• Easy in configuration using DIP switches.
Technical Specifications
Indigenized remote control interface card suitable for MAFI system CCR equipment. Compatible for IDM8000 CCR. Backplane mounted serial and TCP/Ethernet communication module for CCR remote access. IDM 8000 CCR remote control on serial and TCP protocol.
Key Features
Indigenized remote control interface card suitable for MAFI system CCR equipment. Compatible for IDM8000 CCR. Backplane mounted serial and TCP/Ethernet communication module for CCR remote access. IDM 8000 CCR remote control on serial and TCP protocol.
• Remote control: Parallel or serial interface
• Compatible with MAFI CCR system
• Copatiable with IDM8000 CCR
• Compatible with Backplane mount serial communication.
• Compatible with commercial and Defence aviation CCR system.
• Remote control system for accessing CCR and allied system over serial or TCP.
• Indigenized local Support/presence in India.
Application
• Remote control: Parallel or serial interface.
• Compatible with MAFI CCR system.
• Compatible with IDM8000 CCR.
• Compatible with Backplane mount serial communication.
• Compatible with commercial and Defence aviation CCR system.
• Remote control system for accessing CCR and allied system over serial or TCP.
• Indigenized local Support/presence in India.
• Easy in configuration using DIP switches.
Water scarcity is the lack of fresh water resources to meet the standard water demand. There are two type of water scarcity. One is physical. The other is economic water scarcity.
Sachpazis:Terzaghi Bearing Capacity Estimation in simple terms with Calculati...Dr.Costas Sachpazis
Terzaghi's soil bearing capacity theory, developed by Karl Terzaghi, is a fundamental principle in geotechnical engineering used to determine the bearing capacity of shallow foundations. This theory provides a method to calculate the ultimate bearing capacity of soil, which is the maximum load per unit area that the soil can support without undergoing shear failure. The Calculation HTML Code included.
Industrial Training at Shahjalal Fertilizer Company Limited (SFCL)MdTanvirMahtab2
This presentation is about the working procedure of Shahjalal Fertilizer Company Limited (SFCL). A Govt. owned Company of Bangladesh Chemical Industries Corporation under Ministry of Industries.
2. UNDERSTANDING ACCIDENTS
• Accident as an unplanned event that interferes with job or
task completion
• result in some kind of measureable loss such as personal
injury or property damage can cause interruption of
production or other operations & even someone will lose
valuable time dealing with the event
• Accident causes normally result from unsafe acts,
hazardous conditions, or both
• Accident prevention efforts must emphasize development
of necessary policies, procedures, and rules.
• The costs of accidents should provide motivation for senior
leaders to support hazard control efforts.
Common Myths about Accidents
• Accidents result from a single or primary cause.
• Accidents must generate injury or property damage.
• Accidents occur when random variables interact.
• Accidents can result from an act of God or nature.
• Accident investigations must determine fault.
3. Accident Costs
• We can determine the direct costs associated with an
accident.
• However, determining indirect costs can pose a challenge
to the best managers and hazard control managers.
• Traditionally, most hazard control and safety personnel held
the view that indirect costs of an accident far exceed the
calculated direct costs.
• Fred Manuele wrote a thought-provoking article entitled
Accident Costs, Rethinking Ratios of Indirect to Direct Costs,
which appeared in Professional Safety in January of 2001.
• His article encouraged safety to refrain from using any
ratios that data could not accurately support.
• He wisely pointed out that the direct costs of accidents did
increase significantly in recent years due to insurance and
rising medical costs.
5. Henri Heinrich’s 5-Factor Accident Sequence
• Heinrich’s research in the area of accident causation
– 88% of investigated accidents resulted from unsafe acts.
– 10% to unsafe conditions.
– 2% as unpreventable.
• He suggested that and an individual’s life experiences and background
could predispose them to take risks during job accomplishment.
• He believed that removing a single causal factor from a potential
situation could result in preventing an accident.
• Interrupting or breaking the accident cycle by preventing unsafe acts
or correcting an unsafe condition could reduce accident risks for
individuals engaging in risky behaviors.
• Heinrich proposed an accident sequence in which a single causal
factor could actuate the next step in the cycle process.
• He believed that a person’s background and social environment could
impact engagement in faulty behavior.
• Heinrich’s conclusions pointed to what we now refer to as multiple
causation theory.
6. Accident Causes
• System thinking views hazards and causal factors as
moving in logical sequences to produce accident
events.
• Classify causal factors as unsafe acts and unsafe
conditions
• Hazard control personnel should use root cause
analysis (RCA) to discover (information about system
operation, failure, and original design errors),
document, and analyze accident causal factors.
• System-related hazard control efforts focus on unsafe
system conditions and the interaction of human
factors with these.
• Hazard closings can also result in close calls, near hits,
or nearmiss events.
7. Hazard control efforts
• Hazard control management recognizes and acknowledges that
an accident event occurs at a specific point in time
• Many times, previously identified causal factors can interact
resulting in a mishap. These uncontrolled primary factors can
set the accident generation cycle into motion.
• Hazard control efforts must eliminate the hazard or dangerous
situation to reduce or eliminate the potential harm.
• System thinking promotes the concept of providing separation
between an individual and potential operational hazards.
• The hazard may remain within system but in a controlled state.
• Attempt to reduce hazardous exposures by providing controls
such as warning systems, monitoring equipment, and danger
information.
• Attempt to motivate safe behavior through education,
training, and supervision.
8. Multiple Causation Theory
• This theory promotes the idea that accidents result from
various hazards or other factors interacting in some
manner.
• Accident prevention professionals use different descriptors
to describe these factors. Some refer to the factors as
primary and secondary causes, while others use the terms
such as immediate and contributing causes, surface and
root causes, or causes and subcauses.
• Most investigators agree that accidents happen due to
multiple and sometimes complex causal factors.
• Causal factors seldom contribute equally in their ability to
trigger an event or contribute to accident severity.
• Causal factors-Human factors such as an unsafe act, error,
poor judgment, lack of knowledge, and mental impairment
can interact with other contributing factors creating an
opportunity for an accident to occur.
9. Biased Liability Theory
• Biased liability promotes the view that once
an individual becomes involved in an accident,
the chances of that same person becoming
involved in a future accident increases or
decreases when compared to other people.
• The accident proneness theory promotes the
notion that some individuals will simply
experience more accidents than others
because of some personal tendency.
10. Accident Pyramid
• Heinrich introduced the accident pyramid in his book,
Industrial Accident Prevention: A Scientific Approach.
• This pyramid illustrated his accident causation theory.
• Heinrich believed that unsafe acts led first to minor
injuries and then over a period of time to a major injury
event.
• The accident pyramid proposed that 300 unsafe acts
produced 29 minor injuries and 1 major injury.
• The concept of the accident pyramid remained
unchallenged many years. However, some recent studies
challenge the assumed shape of the equilateral triangle
used by Heinrich. Some professionals now believe the
actual shape of the model would depend on organizational
structure and culture.
11.
12. Prevention of Fatal Events
• The March 2003 edition of the journal of Professional
Safety contained an article entitled Severe Injury
Potential.
• The article, authored by Fred Manuele, suggested that
accident prevention efforts should focus more on
preventing fatal events.
• He highlighted some specific examples that lead to
fatalities in industrial settings.
– His list included not controlling hazardous energy,
– no written procedures for hazardous processes,
– failing to ensure physical safeguards,
– using unsafe practices for convenience (risk perceived as
insignificant),
– operating mobile equipment in an unsafe manner.
13. ACCIDENT REPORTING
• The timely and accurate reporting of accidents and injuries
permits an organization to collect and analyze loss-related
information.
• Help to determine patterns and trends of injuries and
illnesses.
• Organizations should encourage reporting by all members.
• Educate all personnel to understand the need for
maintaining a systematic process.
• The system must not only permit data collection but
provide for a means to display any measure of success or
failure in resolving identified hazards.
• Maintain records that enable managers at all levels to
access data.
14. Electronic reporting
• Technology makes reporting and analysis easier and
quicker than ever before.
• Organizations can no longer make excuses for not
accurately collecting, tracking, and evaluating accident,
hazard, and injury information.
• Many vendors offer accident/injury reporting and tracking
software to help the organization save time and money
• Processes permit the creation and printing of electronically
generated reports.
• Make all the forms accessible on your internal computer
network.
• A sample of a completed form will help illustrate and
remind users what information you need from them.
Include a phone number and e-mail address for the person
who can answer questions as they arise.
15. Continued…
• Provide instructions for where and how to submit the
report once completed.
• Electronic submission will save paper and retyping or
scanning.
• Input and track all safety incidents across your organization
through one centralized online portal accessible to all
employees and locations.
• Customize fields, drop-downs & dashboards
• Manage the entire accident life cycle of incident reporting,
responding, investigating, taking corrective action, tracking,
and developing summary reports.
• Incident reporting forms can trigger automatic, escalating
follow-up emails to employees responsible for corrective
actions ensuring prompt resolution.