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1、Accident InvestigationsAlthough accide nt in vestigati on is an after-the-fact approach to hazard identification, it is still an important part of this process. At times hazards exist, which no one seems to recog nize un til they result in an accide nt or in cide nt. In complicated accidents it may

2、take an investigation to actually determine what the cause of the accide nt was. This is especially true in cases where death results and few or no witnesses exist. An accident investigation is a fact-finding process and not a faultfinding process with the purpose of affixing blame. The end of any r

3、esult of an accide nt in vestigatio n should be to assure that the type of hazard or accide nt does not exist or occur in the future.Your compa ny should have a formalized accide nt inv estigati on procedure, which is followed by every one. It should be spelled out in writi ng and end with a writte

4、n report using as a foundation of your standard company accident investigation form. It may be your workers compe nsati on form or an equivale nt from your in sura nee carrier.Accidents and even near misses should be investigated by your company if you are intent on ide ntify ing and preve nting haz

5、ards in your workplace. Thousa nds of accidents occur throughout the United States every day. The failure of people, equipme nt, supplies, or surroundings to behave or react as expected causes most of the accidents. Accident investigations determine how and why these failures occur. By using the in

6、formati on gained through an inv estigati on, a similar or perhaps more disastrous accide nt may be preve nted. Accide nt inv estigati ons should be con ducted with accide nt preve nti on in mind. In vestigati ons are not to place blame.An accide nt is any un pla nned eve nt that results in pers ona

7、l injury or in property damage. When the pers onal injury requires little or no treatment it is mi nor. If it results in a fatality or in a perma nent total, perma nent partial, or temporary total (lost time) disability, it is serious. Similarly, property damage may be minor or serious. Investigate

8、all accident regardless of the extent of injury or damage. Accidents are part of a broad group of eve nts that adversely affect the completi on of a task. These eve nts are in cide nts. For simplicity, the procedures discussed in later sect ions refer only to accide nts. They are, however, also appl

9、icable to in cide nts.1. Accide nt Preve ntio nAccide nts are usually complex. An accide nt may have 10 or more eve nts that can be causes. A detailed an alysis of an accide nt will no rmally reveal three cause levels: basic, in direct, and direct. At the lowest level, an accide nt results only whe

10、n a pers on or object receives an amount of en ergy or hazardous material that cannot be absorbed safely. This energy or hazardous material is the DIRECT CAUSE of the accide nt. The direct cause is usually the result of one or more un safe acts or un safe con diti ons, or both. Un safe acts and con

11、diti ons are the in direct causes or symptoms. In turn, in direct causes are usually traceable to poor man ageme nt policies and decisions, or to personal or environmental factors. These are the basic cause.In spite of their complexity, most accide nts are preve ntable by elim in at ing one or more

12、causes. Accide nt inv estigati ons determ ine not only what happe ned, but also how and why. The in formatio n gained from these in vestigati ons can preve nt recurre nee of similar or perhaps more disastrous accide nt. Accide nt inv estigati ons are in terested in each eve nt as well as in the sequ

13、e nee of eve nts that led to an accide nt. The accide nt type is also importa nt to the inv estigator. The recurre nee of accide nt of a particular type or those with com mon causes shows areas n eedi ng special accide nt preve nti on emphasis.2. In vestigative ProceduresThe actual procedures used i

14、n a particular investigation depend on the nature and results of the accident. The agency having jurisdiction over the lacation determines the adm ini strative procedures. In gen eral, resp on sible officials will appo int an in dividual to be in charge of the inv estigati on. An accide nt inv estig

15、ati on should use most of the followi ng steps:Defined the scope of the investigation.Select the inv estigati on. Assig n specific tasks to each (preferably in writi ng).Present a preliminary briefing to the investigating team.Visit and in spect the accide nt site to get updated in formati on.In ter

16、view each victim and wit ness. Also in terview those who were prese nt before the accide nt and those who arrived at the site shortly after the accide nt. Keep accurate records of each in terview. Use a tape recorder if desired and if approved.Determ ine the follow ing:What was not no rmal before th

17、e accide nt.Where the abno rmality occurred.When it was first no ted.How it occurred.Determ ine the follow ing:Why the accide nt occurred.A likely seque nee of eve nts and probable causes ( direct, in direct, basic ). Alter native seque nces.Determi ne the most likely seque nee of eve nts and the mo

18、st probable causes.Con duct a post-i nv estigati on briefi ng.Prepare a summary report including the recommended actions to prevent a recurre nee. Distribute the report accord ing to applicable in structi ons.An investigation is not complete until all data are analyzed and a final report is complete

19、d. In practice, the investigation work, data analyzed and report preparations proceed simultaneously over much of the time spent on the investigation.3. Fact-Fi ndingInvestigator collects evidence from many sources during an investigation, gets in formatio n from wit nesses and observati on as well

20、as by reports, in terviews witnesses as soon as possible after an accident, inspects the accident site before any cha nges occur, takes photographs and makes sketches of the accide nt sce ne, records all pert inent data on maps, and gets copies of all reports. Docume nts containing no rmal operat in

21、g procedures flow diagrams, maintenance charts or reports of difficulties or abno rmalities are particularly useful. Keep complete and accurate no tes in a bound no tebook. Record pre-accide nt con diti ons, the accide nt seque nce and post- accide nt con diti ons. In additi on, docume nt the locati

22、 on of victims, wit nesses, mach in ery, en ergy source, and hazardous materials.In some investigation, a particular physical or chemical law, principle, or property may expla in a seque nce of eve nts. In clude laws in the no tes take n duri ng the investigation or in the later analysis of data. In

23、 addition, gather data during the investigation that may lend itself to analysis by these laws, principles, or properties. An appe ndix in the final report can in clude an exte nded discussi on.4. In terviewIn gen eral, experie need pers onnel should con duct in terviews. If possible, the team assig

24、 ned to this task should in clude an in dividual with a legal backgro und. After in terviewi ng all wit nesses, the team should an alyze each wit ness statemermay wish to re-i nterview one or more wit nesses to confirm or clarify key poi nts.While there may be incon siste ncies in wit nessesstateme

25、nt, inv estigators shoiassemble the available testimony into a logical order. Analyze this information along with data from the accident site.Not all people react in the same manner to a particular stimulus. For example, a wit ness with in close proximity to the accide nt may have an en tirely diffe

26、re nt story from one who saw it at a distanee. Some witnesses may also change their stories after they have discussed it with others. The reason for the change may be additional clues.A witness who has had a traumatic experienee may not be able to recall the details of the accident. A witness who ha

27、s a vested interest in the result of the in vestigati on may offer biased testim ony. Fin ally, eyesight, heari ng, reacti on time, and the gen eral con diti on of each wit ness may affect his or her powers of observati on. A wit ness may omit en tire seque nces because of a failure to observe them

28、or because their importa nee was not realized.5. Report of Inv estigati onAs no ted earlier, an accide nt in vestigatio n is not complete un til a report is prepared and submitted to proper authorities. Special report forms are available in many cases. Others in sta nces may require a more exte nded

29、 report. Such repots are often very elaborate and may include a cover page, title page, abstract, table of conten ts, comme ntary or n arrative discussi on of probable causes, and a sect ion on con clusi ons and recomme ndatio ns.Accident investigation should be an integral part of your written safe

30、ty and health program. It should be a formal procedure. A successful accide nt inv estigati on determ ines not only what happe ned, but also finds how and why the accide nt occurred. Inv estigatio ns are an effort to preve nt a similar or perhaps more disastrous seque nee of eve nts. You can the n u

31、se the result ing in formati on and recomme ndati ons to preve nt future accide nts.Keep ing records is also very importa nt to recog nizing and reduci ng hazards. A review of accide nt and injury records over a period of time can help pinpoint the cause of view of accide nts. If a certa in worker s

32、hows up several times on the record as being inju red, it may in dicate that the pers on is physically un suited for the job, is not properly trained, or needs better supervision. If one or two occupations experience a high perce ntage of the accide nt in a workplace, they should be carefully an aly

33、zed and coun termeasures should be take n to elimi nate the cause. If there are multiple accide nt involving one machi ne or process, it is possible that work procedures must be cha nged or that maintenance is n eeded. Records that show many accide nts duri ng a short period of time would suggest an

34、 en vir onmen tal problem.Once the hazards have been identified then the information and source must be analyzed to determine their origin and the potential to remove or mitigate their effects upon the workplace. An alysis of hazards forces us to take a serious look at them.事故调查尽管事故调查是一种事后危害识别的方法,它依

35、旧是危害识别的一个重要 组成部分。有时系统中存在人们无法识别的危害,直到事故或事件发生才能得 以辨识。对于复杂的事故,也许经过事故调查才能真正发现事故原因,这种情 况尤其适用于发生人员死亡或缺少目击者的事故。事故调查是一个不断发现事 实的过程而不是以追责为目的的发现错误的过程。一项事故调查的最终结果应 当确定危害或事故不存在或以后不会发生。一个公司应该有一个编制好的事故调查程序,所有员工都应当去遵守它。 这个程序应该以书面方式讲清楚具体过程并最终以标准的公司事故报告格式为 基础编写书面报告。它可能是以员工补偿形式或者保险公司的方式。如果打算识别并且防止工作场所的危害,公司就应当调查事故甚至是未

36、遂 事故。每天美国都会发生万千起事故,人员失误、装置失效、供给不足或环境 缺陷往往是导致大多数事故发生的原因。事故调查可以确定这些失效如何与为 什么发生。通过使用调查获得的信息,一种类似的事故或者也许其他种类灾难 性事故也可以得到有效避免。人们应当牢记事故调查要以事故预防为目的来进 行,而不是追究责任。事故是任何导致人员伤亡或财产损失的计划外的事件。如果人员伤害几乎不 需要治疗,那这种事故就比较低级。如果导致了人员死亡或者整体永久性、部 分永久性或整天暂时性失效,那这种事故就属于严重级别。类似的,财产损失 也可以被分为轻微与严重。事故调查应该无视事故伤害或损伤程度,对所有事 故进行调查。事故是

37、众多阻碍了任务完成的事件的一部分。这些事件又被称为 意外。为了实现简化调查程序,以下部分讨论的程序只涉及到事故,然而它们 也适用于意外事件。1. 事故预防事故往往比较复杂。一起事故可能由十件或更多事件导致。一份详细的事故 分析一般将显示为三种层次的原因:基础的,间接的和直接的。在最低级原因 中,事故只是因为人或物受到了无法承受的一定量的能量或接触了无法吸收的 危害物质。这些能量或危害物质就是事故的直接原因。直接原因经常是一种或 多种不安全行为、不安全环境或者二者共同导致的。不安全行为或环境是间接 原因或征兆。反过来,间接原因经常可以追溯到差劲的管理政策与决定或者人 为与环境因素。这是属于基本原

38、因。尽管事故具有复杂性,通过消除一个或更多起因,大多数事故还是可以预防 的。事故调查不仅可以确定会发生什么,还可以确定事故是如何发生的,为什 么发生。这些调查获得的信息可以帮助防止类似事故再次发生或者可能避免更 多的灾难性事故。事故调查不仅关注每一个事件,而且关注一系列可能导致事 故发生的事件。事故类型对于调查人员也很重要。一种特殊类型事故的再次发 生或者那些拥有共同致因的事故显示了需要特殊事故预防重点的方面。2. 调查程序在一种特定的调查中实际使用的程序取决于事故的性质与结果。在确定管理 程序方面,专门机构的权限高于本公司。一般来说,责任机构将会指定一人负 责调查。事故调查应当要以下步骤的大

39、部分:1确定调查范围2. 选择调查对象,确定所需达到的目标(最好书面记录)3. 向调查小组预先进行简洁汇报4. 参观并检查事故场地,及时更新事故信息5. 访问每一位受害者与目击者,同时还要访问那些事故发生前在场的人员 与事故发生不久后到场的人员。对每一个访问进行准确的记录,如果需要或允 许的情况下可以使用录像带。确定以下信息:1.事故发生前有何异常2异常发生在什么地方3. 什么时候首次被发现4. 如何发生5. 为什么事故会发生6. 可能导致事故发生的一系列原因(直接的,间接的,基础的原因)7. 可替代的一系列原因8. 确定导致事故发生的最可能的原因9. 进行调查后简短的汇报10. 准备总结报告,内容应当包括防止事故再发生的建议措施。根据建议的 适用性分发报告直到所有数据被分析并完成最终报告后,事故调查才能算完成。实践过程 中,调查工作,数据分析和报告准备同时进行,事故调查的大部分时间都用于 这些步骤。3. 事实

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