Mischance Reporting and Examination - PowerPoint PPT Presentation

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Mischance Reporting and Examination

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Mischance Reporting and Examination

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  1. AccidentReporting& Investigation Paul Craythorne Health, Safety & Environmental Advisor

  2. Accident Reporting & Investigation • Course Objectives • to understand: • accident definition • accident causation • accident costs • accident prevention • accident reporting/notification • accident investigation

  3. Accident Reporting & Investigation • Common Uninformed Comments • accidents just happen • we don’t have many accidents • safety is expensive • the insurance will pay • safety is just common sense

  4. Accident Reporting & Investigation • Accident Definition • what is an accident? • unplanned & uncontrolled event that led to, or could have led to: • injury to persons, damage to property/plant/equipment, impairment to the environment or some other loss to the company

  5. Accident Reporting & Investigation • Accident Definition • accident types • minor dangerous occurrence • near miss • plant/equipment damage • minor injury • lost time injury • disablement/fatality

  6. Accident Reporting & Investigation • Accident Definition • Frank Bird (Accident Triangle) • 600 near misses • 30 property damage • 10 minor injuries • 1 serious injury (lost time or fatal)

  7. Accident Reporting & Investigation • Accident Causation • environment • personal fault • unsafe act • unsafe condition • accident • injury/damage

  8. Accident Reporting & Investigation • Accident Causation • causal factors • individual • job • organisation

  9. Accident Reporting & Investigation • Accident Causation • causal factors • individual • knowledge • skills • training • experience • personality • attitude • risk perception

  10. Accident Reporting & Investigation • Accident Causation • causal factors • job • task • workload • equipment • controls • procedures • environment

  11. Accident Reporting & Investigation • Accident Causation • causal factors • organisation • culture • leadership • resources • work patterns • communications

  12. Accident Reporting & Investigation • Accident Causation • Kings Cross Fire (1987) - 31died • discarded cigarette • accumulation of rubbish • poor cleaning regime • wooden escalator • failure of fire fighting equipment • lack of emergency training • poor safety culture

  13. Accident Reporting & Investigation • Accident Causation • Herald of Free Enterprise (1987) - 189 died • failure to close bow doors • no checking/reporting system • commercial pressures • internal friction • disease of sloppiness

  14. Accident Reporting & Investigation • Accident Causation • Clapham Junction (1988) - 35 died & 500 injured • signal failure • incorrect maintenance • degradation of working practices • training problems • communication problems • poor supervision • excessive working hours • failure to learn lessons

  15. Accident Reporting & Investigation • Accident Causation • Piper Alpha (1988) - 167 died • maintenance error • inexperience • poor maintenance procedures • communications breakdown • permit to work system fault • safety procedures not practised

  16. Accident Reporting & Investigation • Accident Causation • Automotive Supplier (1999) - 1 died • poor safety culture • lack of guarding • lack of training • poor perception of risk • no safe systems of work • no risk assessment programme • no effective accident system • no communication

  17. Accident Reporting & Investigation • Accident Costs • insured costs • uninsured costs

  18. Accident Reporting & Investigation • Accident Prevention • reasons • humane • economic • legal

  19. Accident Reporting & Investigation • Accident Prevention • control measures • safety procedures/work instructions • adequate training • effective communications • good housekeeping • guards/safety devices/warning signs • adequate working environment • regular safety inspections • risk assessment

  20. Accident Reporting & Investigation • Accident Reporting/Notification • internal report form • HSE RIDDOR report • injury claim requirement

  21. Accident Reporting & Investigation • Accident Investigation • reasons • identify root causes • identify faults • identify corrective/preventative action • prevent recurrence

  22. Accident Reporting & Investigation • Accident Investigation • investigation team • supervisor • safety rep • engineer • manager • safety officer

  23. Accident Reporting & Investigation • Accident Investigation • investigation objectives • establish chain of events • identify root causes • identify faults • identify corrective/preventative action

  24. Accident Reporting & Investigation • Accident Investigation • investigation techniques • attend promptly • ensure medical attention • leave scene undisturbed • take photographs/sketches • take measurements • take samples • gather documentation • interview witnesses

  25. Accident Reporting & Investigation • Accident Investigation • investigation techniques • interviewing witnesses • explain purpose • their version of events • do not listen to ‘hear say’ • ask open questions • avoiding leading or implying • do not apportion blame • express appreciation

  26. Accident Reporting & Investigation • Accident Investigation • investigation report • identify team • summarise consequential events • identify root causes • describe other weaknesses • identify corrective/preventative action • allocate responsibility & timescale