280 likes | 588 Views
sharif university of technology industrial engineering Safety at work. (Accident Investigation) Razieh shoeleh Roya mohamad ali poor fall2006. What is Ergonomics?. What is an Accident?.
E N D
sharif university of technologyindustrial engineeringSafety at work (Accident Investigation) Razieh shoeleh Roya mohamad ali poor fall2006
What is an Accident? A sequence of logically and chronologically related deviating events involving an incident that results in injury to personnel or damage to the environment or material assets.
The purpose of accident investigation • Identify and describe the true course of events (what, where,when) • Identify the direct and root causes / contributing factors of the accident (why) • Identify risk reducing measures to prevent future, comparable accidents (learning) • Investigate and evaluate the basis for potential criminal prosecution (blame) • Evaluate the question of guilt in order to assess the liability for compensation (pay)
Collecting evidence and facts • Human or testamentary evidence Human or testamentary evidence includes witness statements and observations. • Physical evidence Physical evidence is matter related to the accident (e.g. equipment, parts, debris, hardware, and other physical items). • Documentary evidence Documentary evidence includes paper and electronic information, such as records, reports, procedures, and documentation.
Analysis of evidence and facts • What happened where and when? • Why did it happen? types of causal factors: Direct cause Contributing causes Root causes
Recommendations and reporting • Hendrick and Benner (1987) says that two thoughts should be kept in mind regarding accident reports: • Investigations are remembered trough their reports • The best investigation will be wasted by a poor report.
Methods for accident investigation • TRIPOD • Barrier analysis • Change analysis. • Events and causal factors analysis
OTHER ACCIDENT INVESTIGATION METHODS • Fault tree analysis • Root cause analysis • Events and causal factors charting (ECFC) • Event tree analysis • MORT • Systematic Cause Analysis Technique (SCAT) • (Sequential timed events plotting) • MTO-analysis • Accident Analysis and Barrier Function (AEB) Method • Acci-map
TRIPOD _BETA Definition Advantages Phases: • Diagram Tripod_beta • Hazard conduct • accident causation model
Diagram Tripod_beta Elements • Event • Hazard • Target