Excerpted from my New book: Managing Maintenance Shutdowns and Outages. To be published March 2004 from Industrial Press www.Industrialpress.com
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Accidents and Accident
investigations: An accident happens,
what do we do?
1.
Get the person first
aid or to a hospital (of course).
2.
Deal with the
existing hazards (like PUT THE FIRE OUT) but disturb the scene as little as
possible, in case you want experts to look over the area.
3.
If possible cordon
off the area until the investigation is complete. If possible, photograph
everything immediately after the accident.
4.
Notify any
authorities or insurance companies.
5.
Appropriate parties
should prepare the accident report and report the accident through channels
already established.
6.
Draw up a list of
everyone who has been in the area or has touched that machine or process (both
before and during the shutdown) for questioning. Include operators, engineers,
maintenance workers, contractor workers, and even janitorial personnel.
7.
Conduct interviews
with the people listed. Be patient in interviewing. Let people tell the story
of what happened in their own way at their own pace and tell the story their
own way. Avoid the look, sound and feel of any kind of police investigation.
One goal is to construct a chronology starting well before the event.
8.
Gather all relevant
information about the accident. This should include drawings of the machine,
piping or area, witness statements, medical reports on the condition of the
people (if this is allowed), outside expert reports (such as metallurgy),
diagrams or photos, physical evidence, logs before the accident, work orders,
job packages, company and insurance company investigation reports, and shutdown
records for the job.
9.
Do not investigate to affix blame. Investigate with the intent of finding out what happened. Blame will
shut people down since they might not want to get someone into trouble. Trevor Kletz stresses there is enough blame
for everyone in a typical accident from the craftsperson that took a short cut,
to a designer that made the short cut necessary to the operations chief that
wouldn’t make time for proper training, to the CFO that would not spend the
extra money for a proper isolation system.
10. Gather all cost data. This should include repair and
downtime costs. Include non-financial cost such as accident costs.
11. Accidents have causes at many different levels.
Close examination might show procedure lapses, poor management decisions,
ignorance of parameters and a final unthinking act. All are in the chain of
causes for the accident. Use the data to
find out what your causes are and how you can remove them. Follow the chain
wherever it leads.
12. The focus of the entire investigation is on the
question what
we can do to prevent this type of accident in the future.
All accidents are caused by many interconnected factors. The
factors extend all the way up to the top of the organization (who chose to save
money by eliminating …), to the lowest level (who took a short cut by …). Some
people in the safety field believe that the word accident is inaccurate because
it indicates that the event was out of human control. In fact, accidents are
preventable and more than that they are preventable at many levels by many of
the people up the chain of the organization.
Every shutdown (and plant for that matter) needs a standing safety committee.
The concept and organization of the safety committee is important. The mission
of the safety committee is to determine what can be done to prevent this kind
of event from happening in the future, in every other plant with this hazard.
The second mission is to make sure everyone knows what happened and what the
company is going to do to prevent it in the future. They also look into
determining the way company policy can be modified to prevent similar accidents
in the future, protect the worker's rights, and to involve more of the
organization in the safety program. It is not a passive job the safety
committee members are also safety cheerleaders too.
Safety Committee members could include management, engineers, workers
from the craft or from others, safety, risk management, supervisors etc. The
safety committee should not be too large. Four or five people seem adequate.
Include at least one person from outside the plant (if possible).
Anyone
interested in safety during shutdowns and normal plant operations should read
the works of Trevor Kletz. Titles are in the resource section. I used some
elements of his model for accident investigation in his third edition of Learning
from Accidents.
Joel
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