This document outlines the objectives and procedures for accident and incident prevention and investigation. It discusses determining the causes of accidents, identifying investigation methods, and prevention. The key points covered include defining accidents and incidents, investigating to establish facts and causal factors using a systematic approach, interviewing witnesses, documenting findings, determining effects, and identifying prevention methods. The overall goal is to conduct thorough investigations to prevent future occurrences.
Str-AI-ght to heaven? Pitfalls for clinical decision support based on AIBenVanCalster
This document summarizes some of the key pitfalls and challenges of using artificial intelligence (AI), particularly machine learning and deep learning models, for clinical decision support. It notes that (1) methodology is often poor, with small datasets and a lack of validation; (2) there is little evidence that most models actually improve outcomes; and (3) models show significant heterogeneity and may not generalize across settings and populations. It also discusses issues of proprietary datasets and models, conflicts of interest, and the challenges of actual implementation and assessing real-world impact. The document emphasizes that while AI has potential, more rigorous research is needed to develop trustworthy models that provide reliable decision support for patients and clinicians.
This document discusses root cause analysis and accident investigation. It provides definitions and outlines the process for investigating accidents, including notification, fact-finding, analysis and corrective action. Key aspects covered include identifying direct and root causes, common errors in investigations, and tools for analysis like events and conditions charting, fishbone diagrams and the 5 whys technique. The goal is to develop effective corrective measures by thoroughly understanding causal factors in order to prevent future accidents.
An accident investigation aims to improve safety by exploring the causes of events and identifying remedies. All accidents, regardless of severity, should be investigated to some degree to understand root causes. A thorough investigation involves collecting evidence from the scene, documents, and witness interviews without blame. The investigation process determines immediate causes like unsafe acts or conditions, as well as underlying causes involving management systems. The results are recorded and analyzed to identify corrective actions and prevent future occurrences.
An extension on hypothesis testing, this lesson introduces the concepts of a correlation and regression as part of measuring statistical relationships.
Too many companies throw money at canned programs instead of investing in the one group best equipped to lead them to safety and operational excellence. Truth is, everything they pay for in a BBS program that has any positive effect on their safety they could do themselves for free.
This document outlines the objectives and procedures for accident and incident prevention and investigation. It discusses determining the causes of accidents, identifying investigation methods, and prevention. The key points covered include defining accidents and incidents, investigating to establish facts and causal factors using a systematic approach, interviewing witnesses, documenting findings, determining effects, and identifying prevention methods. The overall goal is to conduct thorough investigations to prevent future occurrences.
Str-AI-ght to heaven? Pitfalls for clinical decision support based on AIBenVanCalster
This document summarizes some of the key pitfalls and challenges of using artificial intelligence (AI), particularly machine learning and deep learning models, for clinical decision support. It notes that (1) methodology is often poor, with small datasets and a lack of validation; (2) there is little evidence that most models actually improve outcomes; and (3) models show significant heterogeneity and may not generalize across settings and populations. It also discusses issues of proprietary datasets and models, conflicts of interest, and the challenges of actual implementation and assessing real-world impact. The document emphasizes that while AI has potential, more rigorous research is needed to develop trustworthy models that provide reliable decision support for patients and clinicians.
This document discusses root cause analysis and accident investigation. It provides definitions and outlines the process for investigating accidents, including notification, fact-finding, analysis and corrective action. Key aspects covered include identifying direct and root causes, common errors in investigations, and tools for analysis like events and conditions charting, fishbone diagrams and the 5 whys technique. The goal is to develop effective corrective measures by thoroughly understanding causal factors in order to prevent future accidents.
An accident investigation aims to improve safety by exploring the causes of events and identifying remedies. All accidents, regardless of severity, should be investigated to some degree to understand root causes. A thorough investigation involves collecting evidence from the scene, documents, and witness interviews without blame. The investigation process determines immediate causes like unsafe acts or conditions, as well as underlying causes involving management systems. The results are recorded and analyzed to identify corrective actions and prevent future occurrences.
An extension on hypothesis testing, this lesson introduces the concepts of a correlation and regression as part of measuring statistical relationships.
Too many companies throw money at canned programs instead of investing in the one group best equipped to lead them to safety and operational excellence. Truth is, everything they pay for in a BBS program that has any positive effect on their safety they could do themselves for free.
Development and evaluation of prediction models: pitfalls and solutions (Part...BenVanCalster
Slides for the statistics in practice session for the Biometrisches Kolloquium (organized by the Deutsche Region der Internationalen Biometrischen Gesellschaft), 16 March 2021.
Part I from Maarten van Smeden: https://www.slideshare.net/MaartenvanSmeden/development-and-evaluation-of-prediction-models-pitfalls-and-solutions
This document discusses foundational concepts for effective incident investigations. It argues that not everyone can investigate incidents well just by following basic procedures and training. Effective investigations require understanding key concepts like using appropriate terminology and models. The presentation contrasts egocentric models that focus on failure and human error with ergonomic models that examine all factors contributing to an interaction. The goal of investigation is to change the future by identifying controls, not blame. Effective investigations account for human, equipment and environmental capabilities to find engineering solutions rather than just fixing failures.
This document provides information on accident investigation and prevention. It begins with an introduction of Yawar Hassan Khan as a certified HSE professional. It then defines an accident and common accident types. The document discusses theories on accident causation and emphasizes a systems approach. It outlines responsibilities and procedures for accident investigation including securing the scene, interviews, analyzing the sequence of events and causes. Recommendations are made to correct hazardous conditions. The goal is prevention, not fault-finding. Interview techniques and analyzing accident factors, hazardous conditions, unsafe behaviors and system weaknesses are covered. The report format includes background, description, findings, recommendations and summary. Feedback is welcomed.
1) The document discusses how to properly optimize predictive models, noting that squared error is convenient for computers but not clients, and AUC should never be directly optimized. 2) It recommends using lift charts and customizing the optimization metric to the specific goals and needs of each project. 3) Higher-level considerations include brainstorming the overall goals and priorities of a project, and selecting projects based on their potential ROI, costs, and other factors.
The document provides an overview of incident investigation and root cause analysis. It discusses conducting an investigation by securing the incident scene, interviewing witnesses, developing a sequence of events, and performing different levels of analysis including injury analysis, surface cause analysis, and root cause analysis to identify the underlying causes. Root cause analysis seeks to identify weaknesses in the safety management system that contributed to the incident. Effective recommendations should propose both immediate corrective actions and long-term system improvements to policies, programs, and procedures.
This document outlines the process for investigating accidents and incidents. It defines an accident investigation as an important part of a safety management system that highlights why accidents occur and how to prevent them. The primary goals of an investigation are to identify the immediate and root causes of events and implement remedies to improve safety. All accidents, regardless of severity, should be investigated to some degree to identify common causes and trends. The stages of an investigation include dealing with immediate risks, selecting an investigation level, investigating the event, recording and analyzing results, and reviewing the process. Thorough observation, documentation review, and interviews are important for determining causes. Remedial actions should follow a hierarchy of risk control from elimination to engineering to administrative controls.
This document provides an overview of conducting effective incident/accident analysis through a 6 step process: 1) Secure the accident scene, 2) Collect facts, 3) Determine sequence of events, 4) Determine causes, 5) Recommend improvements, 6) Write the report. The objectives are to describe reasons for investigations, discuss employer responsibilities, and demonstrate the 6 step procedure. Key aspects covered include interviewing techniques, root cause analysis methods, recommending corrective actions through engineering and management controls, and improving safety management systems.
This presentation covers accident investigation for supervisors. It aims to explain the need for and benefits of accident investigations, and provide the tools and information to properly complete investigations. The presentation outlines a 6-step accident investigation process: collecting information on-site and off-site, determining causes, assessing future potential, correcting causes, reporting recommendations, and taking/monitoring corrective action. Key aspects discussed include defining roles and responsibilities, identifying which accidents to investigate, determining root and contributory causes, and ensuring investigations identify all underlying causes.
This document provides guidance on incident management and root cause analysis for NHS screening programs. It describes what constitutes a screening safety incident and outlines requirements for managing safety concerns, incidents, and serious incidents. The Safety Incident Assessment Form is used for fact-finding and recommending actions. It also discusses accountability, roles, and responsibilities and recommends using a RASCI framework. Root cause analysis is described as an evidence-based process to identify the underlying causes of problems in order to develop targeted actions to prevent recurrence.
This document provides guidance on incident management and root cause analysis for NHS screening programs. It describes what constitutes a screening safety incident and outlines requirements for managing safety concerns, incidents, and serious incidents. The Safety Incident Assessment Form is used for fact-finding and recommending actions. It also discusses accountability, roles, and responsibilities and recommends using a RASCI framework. Root cause analysis is described as an evidence-based process to identify the underlying causes of problems in order to develop targeted actions to prevent recurrence.
Root Cause Analysis – A Practice to Understanding and Control the Failure Man...inventionjournals
International Journal of Business and Management Invention (IJBMI) is an international journal intended for professionals and researchers in all fields of Business and Management. IJBMI publishes research articles and reviews within the whole field Business and Management, new teaching methods, assessment, validation and the impact of new technologies and it will continue to provide information on the latest trends and developments in this ever-expanding subject. The publications of papers are selected through double peer reviewed to ensure originality, relevance, and readability. The articles published in our journal can be accessed online.
This document provides an overview of root cause analysis (RCA) and corrective and preventive action (CAPA) processes. It defines failure, outlines objectives of investigations such as corrective actions and preventive actions. It discusses quality of investigations and common but incorrect initial responses. The document then covers starting an RCA with a positive mindset, avoiding bias, not blaming individuals, and effective teamwork. Steps in an investigation and CAPA process are defined including identification, risk assessment, immediate action, root cause analysis, action planning, implementation and follow-up. Tools for root cause analysis like brainstorming, field trips, 5 whys, and Ishikawa diagrams are described.
RCA is a process analysis method used to identify the underlying causes of adverse events. It aims to determine what happened, why it occurred, and how to prevent recurrence. RCA investigations focus on systems and processes rather than individual performance. They should be initiated promptly for high risk incidents and completed within 2 months. The major steps include defining the problem, mapping timelines, identifying causes, developing recommendations, and writing a report with conclusions and risk reduction plans. The goal is to convert causal findings into actions to mitigate risks and ensure safety.
The document describes elements of an effective safety and health management program. It discusses establishing a policy and demonstrating management commitment. Elements include conducting hazard analyses, inspections, and accident investigations to identify risks. The document also covers implementing controls, training employees, and establishing procedures for emergencies and reporting unsafe conditions. Developing a comprehensive management system can help prevent injuries and illnesses by integrating safety into all operations and activities.
Maximo Oil and Gas 7.6.1 HSE: Investigations overviewHelen Fisher
Example use cases:
-Safety related incident investigations
Process Safety
Occupational Health and Safety
Human factors
-Reliability investigations
-Environmental investigations
-Quality investigations
The document provides guidance on conducting workplace accident investigations. It defines accidents and incidents, explaining that incidents should also be investigated as they represent near misses. The key steps outlined are: developing an investigation plan and kit in advance, immediately investigating all incidents and accidents to collect facts and interview witnesses, determining the root causes through methods like 5 Whys, and writing a report of findings and recommendations. Conducting thorough investigations can help identify hazards and prevent future accidents.
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.
This document summarizes a student's research project assessing Technip's health, safety, and environment (HSE) standards and procedures for its onshore operations in Ghana. The research included a literature review, interviews, and analysis of Technip's risk assessment activities and HSE standards. Some discrepancies were found between Technip's written standards and actual on-site practices. The research identified overconfidence and negligence as leading causes of accidents. Recommendations included improving job risk assessments, standardizing personal protective equipment requirements, and increasing HSE awareness training.
The document discusses various techniques for problem analysis that can be used to identify the root causes of issues in organizations. It outlines models and methods like force field analysis, fishbone diagram, five whys, cause-and-effect analysis and interrelationship digraph that can help analyze problems systematically. These techniques verify the problem, identify potential causes through tools like brainstorming, and trace the line of causality to determine the key factors contributing to an identified effect or problem.
Development and evaluation of prediction models: pitfalls and solutions (Part...BenVanCalster
Slides for the statistics in practice session for the Biometrisches Kolloquium (organized by the Deutsche Region der Internationalen Biometrischen Gesellschaft), 16 March 2021.
Part I from Maarten van Smeden: https://www.slideshare.net/MaartenvanSmeden/development-and-evaluation-of-prediction-models-pitfalls-and-solutions
This document discusses foundational concepts for effective incident investigations. It argues that not everyone can investigate incidents well just by following basic procedures and training. Effective investigations require understanding key concepts like using appropriate terminology and models. The presentation contrasts egocentric models that focus on failure and human error with ergonomic models that examine all factors contributing to an interaction. The goal of investigation is to change the future by identifying controls, not blame. Effective investigations account for human, equipment and environmental capabilities to find engineering solutions rather than just fixing failures.
This document provides information on accident investigation and prevention. It begins with an introduction of Yawar Hassan Khan as a certified HSE professional. It then defines an accident and common accident types. The document discusses theories on accident causation and emphasizes a systems approach. It outlines responsibilities and procedures for accident investigation including securing the scene, interviews, analyzing the sequence of events and causes. Recommendations are made to correct hazardous conditions. The goal is prevention, not fault-finding. Interview techniques and analyzing accident factors, hazardous conditions, unsafe behaviors and system weaknesses are covered. The report format includes background, description, findings, recommendations and summary. Feedback is welcomed.
1) The document discusses how to properly optimize predictive models, noting that squared error is convenient for computers but not clients, and AUC should never be directly optimized. 2) It recommends using lift charts and customizing the optimization metric to the specific goals and needs of each project. 3) Higher-level considerations include brainstorming the overall goals and priorities of a project, and selecting projects based on their potential ROI, costs, and other factors.
The document provides an overview of incident investigation and root cause analysis. It discusses conducting an investigation by securing the incident scene, interviewing witnesses, developing a sequence of events, and performing different levels of analysis including injury analysis, surface cause analysis, and root cause analysis to identify the underlying causes. Root cause analysis seeks to identify weaknesses in the safety management system that contributed to the incident. Effective recommendations should propose both immediate corrective actions and long-term system improvements to policies, programs, and procedures.
This document outlines the process for investigating accidents and incidents. It defines an accident investigation as an important part of a safety management system that highlights why accidents occur and how to prevent them. The primary goals of an investigation are to identify the immediate and root causes of events and implement remedies to improve safety. All accidents, regardless of severity, should be investigated to some degree to identify common causes and trends. The stages of an investigation include dealing with immediate risks, selecting an investigation level, investigating the event, recording and analyzing results, and reviewing the process. Thorough observation, documentation review, and interviews are important for determining causes. Remedial actions should follow a hierarchy of risk control from elimination to engineering to administrative controls.
This document provides an overview of conducting effective incident/accident analysis through a 6 step process: 1) Secure the accident scene, 2) Collect facts, 3) Determine sequence of events, 4) Determine causes, 5) Recommend improvements, 6) Write the report. The objectives are to describe reasons for investigations, discuss employer responsibilities, and demonstrate the 6 step procedure. Key aspects covered include interviewing techniques, root cause analysis methods, recommending corrective actions through engineering and management controls, and improving safety management systems.
This presentation covers accident investigation for supervisors. It aims to explain the need for and benefits of accident investigations, and provide the tools and information to properly complete investigations. The presentation outlines a 6-step accident investigation process: collecting information on-site and off-site, determining causes, assessing future potential, correcting causes, reporting recommendations, and taking/monitoring corrective action. Key aspects discussed include defining roles and responsibilities, identifying which accidents to investigate, determining root and contributory causes, and ensuring investigations identify all underlying causes.
This document provides guidance on incident management and root cause analysis for NHS screening programs. It describes what constitutes a screening safety incident and outlines requirements for managing safety concerns, incidents, and serious incidents. The Safety Incident Assessment Form is used for fact-finding and recommending actions. It also discusses accountability, roles, and responsibilities and recommends using a RASCI framework. Root cause analysis is described as an evidence-based process to identify the underlying causes of problems in order to develop targeted actions to prevent recurrence.
This document provides guidance on incident management and root cause analysis for NHS screening programs. It describes what constitutes a screening safety incident and outlines requirements for managing safety concerns, incidents, and serious incidents. The Safety Incident Assessment Form is used for fact-finding and recommending actions. It also discusses accountability, roles, and responsibilities and recommends using a RASCI framework. Root cause analysis is described as an evidence-based process to identify the underlying causes of problems in order to develop targeted actions to prevent recurrence.
Root Cause Analysis – A Practice to Understanding and Control the Failure Man...inventionjournals
International Journal of Business and Management Invention (IJBMI) is an international journal intended for professionals and researchers in all fields of Business and Management. IJBMI publishes research articles and reviews within the whole field Business and Management, new teaching methods, assessment, validation and the impact of new technologies and it will continue to provide information on the latest trends and developments in this ever-expanding subject. The publications of papers are selected through double peer reviewed to ensure originality, relevance, and readability. The articles published in our journal can be accessed online.
This document provides an overview of root cause analysis (RCA) and corrective and preventive action (CAPA) processes. It defines failure, outlines objectives of investigations such as corrective actions and preventive actions. It discusses quality of investigations and common but incorrect initial responses. The document then covers starting an RCA with a positive mindset, avoiding bias, not blaming individuals, and effective teamwork. Steps in an investigation and CAPA process are defined including identification, risk assessment, immediate action, root cause analysis, action planning, implementation and follow-up. Tools for root cause analysis like brainstorming, field trips, 5 whys, and Ishikawa diagrams are described.
RCA is a process analysis method used to identify the underlying causes of adverse events. It aims to determine what happened, why it occurred, and how to prevent recurrence. RCA investigations focus on systems and processes rather than individual performance. They should be initiated promptly for high risk incidents and completed within 2 months. The major steps include defining the problem, mapping timelines, identifying causes, developing recommendations, and writing a report with conclusions and risk reduction plans. The goal is to convert causal findings into actions to mitigate risks and ensure safety.
The document describes elements of an effective safety and health management program. It discusses establishing a policy and demonstrating management commitment. Elements include conducting hazard analyses, inspections, and accident investigations to identify risks. The document also covers implementing controls, training employees, and establishing procedures for emergencies and reporting unsafe conditions. Developing a comprehensive management system can help prevent injuries and illnesses by integrating safety into all operations and activities.
Maximo Oil and Gas 7.6.1 HSE: Investigations overviewHelen Fisher
Example use cases:
-Safety related incident investigations
Process Safety
Occupational Health and Safety
Human factors
-Reliability investigations
-Environmental investigations
-Quality investigations
The document provides guidance on conducting workplace accident investigations. It defines accidents and incidents, explaining that incidents should also be investigated as they represent near misses. The key steps outlined are: developing an investigation plan and kit in advance, immediately investigating all incidents and accidents to collect facts and interview witnesses, determining the root causes through methods like 5 Whys, and writing a report of findings and recommendations. Conducting thorough investigations can help identify hazards and prevent future accidents.
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.
This document summarizes a student's research project assessing Technip's health, safety, and environment (HSE) standards and procedures for its onshore operations in Ghana. The research included a literature review, interviews, and analysis of Technip's risk assessment activities and HSE standards. Some discrepancies were found between Technip's written standards and actual on-site practices. The research identified overconfidence and negligence as leading causes of accidents. Recommendations included improving job risk assessments, standardizing personal protective equipment requirements, and increasing HSE awareness training.
The document discusses various techniques for problem analysis that can be used to identify the root causes of issues in organizations. It outlines models and methods like force field analysis, fishbone diagram, five whys, cause-and-effect analysis and interrelationship digraph that can help analyze problems systematically. These techniques verify the problem, identify potential causes through tools like brainstorming, and trace the line of causality to determine the key factors contributing to an identified effect or problem.
The document discusses the reasons for investigating accidents and incidents in the workplace. Key reasons include: to prevent future accidents by identifying their root causes; to fulfill legal requirements; to address liability issues if problems are not corrected; and most importantly, to improve workplace safety and protect employee health. A thorough investigation process is an important part of any safety program.
Occupational health and safety management systems are used to identify hazards and manage risk. These tools are effective when used correctly to reduce liability, reduce operating cost, improve morale and corporate culture, worker job satisfaction, increase productivity and profitability, sustainable business development and projections for expansion, reduce financial risk, and improvement on company brand, reputation, and image.
This document discusses risk assessments and managing safety. It addresses why risk assessments are necessary, how effective the risk assessment process is, and the importance of leadership and supervision. While risk assessments are one part of reducing accidents, the document notes their weaknesses and that simply having a process does not guarantee effectiveness. Leadership, monitoring safety procedures, training, and supervision are also critical to properly implementing risk assessments and improving safety. The document questions whether some accidents are inevitable and explores examples of why signs and regulations may not alone "prevent" accidents without the right leadership and culture.
A study of construction oil & gas in malaysia impact of safety management on ...(NV)Vasuki vadamalai MBA
1. Introduction
Safety can be defining as by eliminating risk. As according to Hollnagel,2009 he describes as “the freedom from unacceptable risks” (Hollanagel,2009)
1.1. Introduction of safety Management
Safety management is basically more to managing business activities in construction site to prevent accident or minimize injury. Indeed, all these being under occupational health and safety management system effectiveness in construction oil and gas. Impact on safety management system (SMS), those who working in construction by managing safety policies and procedures such as organizing, planning, direct, creating event of safety awareness as leading (Stolzer et al,2010) (Flouris, and Yilmaz ,2011)
1.2 Overview of Construction industry
The most injury and accident happen in construction oil & gas industry include fatal or nonfatal injures or accident. The construction worker exposes more to hazard lead to early retirement. Malaysian start develops with construction work to become develop country which Malaysia allocated budget for country transformation (Lewis,1955). This is also one way to attract local or foreign investor to our country.
Improving safety precaution and step preventing serious injury or accident happen at construction is hardly to monitor as the environment situation and safety management system applied (Gibb and Bust 2006, Koehn et al. 1995). In addition, the workers behavior and occupational health and safety management system efficiency status is questionable
1.3. Construction Industry in Malaysia
Malaysian growth is supported by government and construction industry was growing rapidly. In fact, is it not easy to manage safety management in construction oil and gas business (Betts and ofori, 1992).
1.3.1 Malaysia politic, economic status, local cultural
1.3.2 The Malaysia context study
Malaysia need take serious on security and safety management that involve political,economic,social and evironmental (Buzan,1998).Security is play important part on safety management operation efficiency and for malaysia economic growth to avoid threat of lowering currency value.
The document provides an overview of Failure Mode and Effect Analysis (FMEA) and its use in healthcare. It defines FMEA and explains its benefits, such as aimed at prevention and making systems more robust. The document also outlines the healthcare FMEA process which includes defining the topic, assembling a team, describing the process graphically, conducting a hazard analysis to identify failures and effects, and identifying actions and outcome measures.
Hazop (incident investigation & root cause analysis )umar farooq
The document discusses incident investigation and root cause analysis. It defines key terms like incident, accident, near miss, unsafe acts, and injuries. It outlines the typical incident investigation process, which includes initial reporting, analysis, a full investigation, an investigation report, identifying trends and corrective actions. The investigation process aims to determine the root causes of incidents by gathering facts about what happened, how and why through interviews and examining the site. The goal is to recommend actions to prevent future recurrence.
Similar to The Quality of Accident Investigation in the tier-one Australian Construction Industry (20)
Level 3 NCEA - NZ: A Nation In the Making 1872 - 1900 SML.pptHenry Hollis
The History of NZ 1870-1900.
Making of a Nation.
From the NZ Wars to Liberals,
Richard Seddon, George Grey,
Social Laboratory, New Zealand,
Confiscations, Kotahitanga, Kingitanga, Parliament, Suffrage, Repudiation, Economic Change, Agriculture, Gold Mining, Timber, Flax, Sheep, Dairying,
This presentation was provided by Rebecca Benner, Ph.D., of the American Society of Anesthesiologists, for the second session of NISO's 2024 Training Series "DEIA in the Scholarly Landscape." Session Two: 'Expanding Pathways to Publishing Careers,' was held June 13, 2024.
A Visual Guide to 1 Samuel | A Tale of Two HeartsSteve Thomason
These slides walk through the story of 1 Samuel. Samuel is the last judge of Israel. The people reject God and want a king. Saul is anointed as the first king, but he is not a good king. David, the shepherd boy is anointed and Saul is envious of him. David shows honor while Saul continues to self destruct.
THE SACRIFICE HOW PRO-PALESTINE PROTESTS STUDENTS ARE SACRIFICING TO CHANGE T...indexPub
The recent surge in pro-Palestine student activism has prompted significant responses from universities, ranging from negotiations and divestment commitments to increased transparency about investments in companies supporting the war on Gaza. This activism has led to the cessation of student encampments but also highlighted the substantial sacrifices made by students, including academic disruptions and personal risks. The primary drivers of these protests are poor university administration, lack of transparency, and inadequate communication between officials and students. This study examines the profound emotional, psychological, and professional impacts on students engaged in pro-Palestine protests, focusing on Generation Z's (Gen-Z) activism dynamics. This paper explores the significant sacrifices made by these students and even the professors supporting the pro-Palestine movement, with a focus on recent global movements. Through an in-depth analysis of printed and electronic media, the study examines the impacts of these sacrifices on the academic and personal lives of those involved. The paper highlights examples from various universities, demonstrating student activism's long-term and short-term effects, including disciplinary actions, social backlash, and career implications. The researchers also explore the broader implications of student sacrifices. The findings reveal that these sacrifices are driven by a profound commitment to justice and human rights, and are influenced by the increasing availability of information, peer interactions, and personal convictions. The study also discusses the broader implications of this activism, comparing it to historical precedents and assessing its potential to influence policy and public opinion. The emotional and psychological toll on student activists is significant, but their sense of purpose and community support mitigates some of these challenges. However, the researchers call for acknowledging the broader Impact of these sacrifices on the future global movement of FreePalestine.
Temple of Asclepius in Thrace. Excavation resultsKrassimira Luka
The temple and the sanctuary around were dedicated to Asklepios Zmidrenus. This name has been known since 1875 when an inscription dedicated to him was discovered in Rome. The inscription is dated in 227 AD and was left by soldiers originating from the city of Philippopolis (modern Plovdiv).
How Barcodes Can Be Leveraged Within Odoo 17Celine George
In this presentation, we will explore how barcodes can be leveraged within Odoo 17 to streamline our manufacturing processes. We will cover the configuration steps, how to utilize barcodes in different manufacturing scenarios, and the overall benefits of implementing this technology.
The Quality of Accident Investigation in the tier-one Australian Construction Industry
1. 1
The Quality of Accident Investigation in the tier-one Australian Construction Industry
By Andrew Summers – Masters AINV (Central Queensland University)
October 2016
TABLE 1 – Industry representation: The data outlines that 78% of the total participants
work from the construction industry. This provides a good sample size when considering
transient employment.
TABLE 2 – Number of Investigations: This question asked to ensure that research wasn’t
targeting minority groups with little previous experience in accident investigation. Of the 33
participants, 51% have conducted seven or more investigations in the past twelve months
(September 2015 - August 2016).
2. 2
1. HST Manager
2. Super awesome HSE guy!
3. NSW Operations Manager of a safety consultancy
4. Safety Manager
5. WHS Manager
6. Safety Manager
7. Principal Safety Manager
8. Construction manager
9. Environmental Consultant
10. Safety Advisor
11. ANZ HSE Manager
12. HSE manager
13. General Manager EHS - International Businesses
14. Safety Advisor
15. WHS Consultant
16. Head of Safety
17. Group GM HSEQ
18. HS Manager
19. Principal Advisor – Safety
20. Senior Safety Advisor
21. Safety manager
22. Project Safety Manager
23. WHS & Risk Consultant
24. Safety Manager
25. Safety Manager
26. EHS Manager
27. Project Director
28. HSE Advisor
29. Safety Manager
30. Senior Safety Advisor
31. Construction Manager
32. Safety Manager
33. Ex-WorkSafe investigator
TABLE 3 – Job title: With the exception of participants #8,9,27 & 31, the job titles of the
research participants appear to come from a HSE background, equating to 29 (87%).
3. 3
TABLE 4 – Company size: 63% of the research participants comes from large Australian
organisations who employ greater than 1001 employees.
TABLE 5 – Historic employment: 57% of participants have worked for 3+ employers in the
last 10 years
4. 4
TABLE 6 – Investigation methods: The result demonstrates that the investigation scenarios
that are primarily conducted within the Australian construction industry vary, with only 15%
equating to simple linear investigations.
TABLE 7 – Employers investigation standards: A mixed result from participants with 48%
agreeing that their company do accident investigations well, while 30% believing their
company does not do accident investigations well.
6. 6
TABLE 8 – Employers investigation techniques: This outlines that 84% of participant
employers use the ICAM causation technique.
TABLE 9 – Workplace investigation procedure: 21% of participants do not have a procedure
or checklist for following/referring to when conducting accident investigations.
7. 7
TABLE 10 – Industry investigation standards: 40% of participants believe that the industry
does accident investigations well.
TABLE 11 – Peer reviewed investigations: 70% of the participants agree or strongly agree
with accident investigation get reviewed and approved by peers.
8. 8
TABLE 12 – Quality assurance techniques: 84% of research participants agree that a
minimal standard of quality should be met.
TABLE 13 – Quality assurance training: This data represents the view that participants agree
or strongly agree (80%) that a quality assurance process is needed in the curriculum for
teaching causation techniques.
9. 9
TABLE 14 – Investigation training: 96% of participants have undertaken accident training to
some extent.
TABLE 15 – National investigation curriculum: It is agreed and strongly agreed (85%) that a
national accident investigation curriculum should be in place for accident investigation
training.
10. 10
TABLE 16 – Investigation facilitators: 100% of participants agree or strongly agree that
facilitators of investigations should receive ‘appropriate’ training.
TABLE 17 – Training by RTO’s: 64% of participants agree or strongly agree that accident
investigator training should be done by Registered Training Organisations (RTO’s).
11. 11
TABLE 18 – Training duration: Short term Accident Investigation training equates to 45% of
the participants overall training.
12. 12
TABLE 19 – Causation techniques: 84% of research participants have undertaken ICAM
training, with TapRoot and Why Tree coming in 2nd and third respectively.
13. 13
TABLE 20 – Transient employment: 26 research participants (78%) agree or strongly agree
that prescribed accident investigation techniques would assist the transient construction
worker.
TABLE 21 – Prescribing fundamentals: 66% of participants either agree or strongly agree
that in order to get consistent quality investigations, that the WHS legislation should
prescribe fundamental investigation obligations.
14. 14
TABLE 22 – If not, Why not: The “if not, why not” clause was supported by 64% of research
participants either agreeing or strongly agreeing.
TABLE 23 – Minimum standards: 80% of participants either agree or strongly agree that
minimum accident investigation fundamentals should be reported on a prescribed template
to ensure certain event information is investigated.
15. 15
TABLE 24 – Completing investigations: The proposed idea of having an approved accident
investigator from a PCBU who would maintain accreditation so that a quality standard could
be met had 33% of respondents disagree or strongly disagree to the idea.
TABLE 25 – Amending legislation: Prescribing WHS legislation with minimum standards was
agreed or strongly agreed with 73% of participants.
16. 16
TABLE 26 – Investigation photos: 87% of research participants agree or strongly agree that
incident scene photographs with added commentary helps explain accident causation.
TABLE 27 – Logic diagrams: 79% of participants agree or strongly agree with the belief that
logic diagrams help explain causation logic, with 0% believing the contrary.
17. 17
TABLE 28 – Causation logic: Supporting table 26, 60% of research participants include logic
diagrams to help explain logic in their investigations.
TABLE 29 – Benefits of Logic Diagrams: 66% of participants say yes to logic diagrams being
needed to demonstrate logic in accident investigation reports.
18. 18
TABLE 30 – Participant perspectives: 87% of participants believe that Root cause can occur
multiple times within an event of an accident, with 18% disagreeing or strongly disagreeing
with this claim.
19. 19
1. Root Cause is the basic cause or the fundamental problem that resulted in the incident to occur. If we
are talking about energies, it is the path that allowed the energy to result in an incident or event.
2. An underlying condition or set of conditions that allowed the proximal causes of an incident to develop.
3. The underlying system failure that permitted the failures/errors to occur that lead to the event. The fifth
of the five whys
4. Identifying a reason that an incident occurred
5. One event that led to an incident occurring.
6. The fundamental cause, or causes, of an event or chain of events
7. My interpretation of root cause is the main cause of a particular incident. There may have been other
contributing factors that lead up to a specific incident, but there was a specific cause that resulted in an
incident
8. To find the key reason or more likely reasons why an accident or incident has taken place.
9. A viewpoint of the factors leading to an incident at a given point of time
10. Is the main cause after an incident occurred based on the investigation
11. Deeply embedded faults within an organisations or an individuals practice or process that if unfetted can
peculate to more likely cause or contribute to incidents
12. If controlled the event would not have happened
13. Identification of the primary cause/s of the event - those that if did not occur, would have prevented the
event from occurring.
14. The original causal factor that sets off a series of other causal factors, which align to create an event.
15. The last failure that occurred resulting in release of energy, could have many contributing factors
16. A misnomer as there are normally several causes if you dig deeply enough
17. . (no answer)
18. When the money runs out or we stop looking. Absence of best practise.
19. The primary causation of the event.
20. What directly caused the accident to occur
21. there is often more than one cause of an incident, as such i don’t think the root cause term adds merit
22. Root cause is a meaningful cause that leads to a sequence of events. Without the root cause the event
wouldn’t have occurred.
23. Identifying the systemic, management actions or behaviours which existed as the underlying cause
which created a situation for the event to occur
24. It’s the fundamental reason for the occurrence
25. The primary cause leading to the incident/near hit.
26. Drilling down to the actual cause which may not associated with site conditions
27. Fundamental reason for the occurrence
28. Failure of system that caused incident
29. Underlying reason/s that set the environment prior to or at the time of the incident
30. The basic definitive reason as to why the event happened
31. What is the one element, which if it did not exist, the incident would not have occurred.
32. The thing or thing that management has control over that if in a correct state, will not lead to an incident.
33. Not applicable in my methodology
TABLE 31 – Root cause: The research participant’s responses on their interpretation of the
meaning of root cause.