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1、Accident InvestigationsAlthough accident investigation 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 recognize until they result in an accident or incident. In complicated accidents it may take an
2、investigation to actually determine what the cause of the accident 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 fault-finding process with the purpose of affixing blame. The end of any result of
3、 an accident investigation should be to assure that the type of hazard or accident does not exist or occur in the future.Your company should have a formalized accident investigation procedure, which is followed by everyone. It should be spelled out in writing and end with a written report using as a
4、 foundation of your standard company accident investigation form. It may be your workers compensation form or an equivalent from your insurance carrier.Accidents and even near misses should be investigated by your company if you are intent on identifying and preventing hazards in your workplace. Tho
5、usands of accidents occur throughout the United States every day. The failure of people, equipment, 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 information gained through an in
6、vestigation, a similar or perhaps more disastrous accident may be prevented. Accident investigations should be conducted with accident prevention in mind. Investigations are not to place blame.An accident is any unplanned event that results in personal injury or in property damage. When the personal
7、 injury requires little or no treatment,it is minor. If it results in a fatality or in a permanent total, permanent partial, or temporary total (lost time) disability, it is serious. Similarly, property damage may be minor or serious. Investigate all accident regardless of the extent of injury or da
8、mage. Accidents are part of a broad group of events that adversely affect the completion of a task. These events are incidents. For simplicity, the procedures discussed in later sections refer only to accidents. They are, however, also applicable to incidents.1. Accident PreventionAccidents are usua
9、lly complex. An accident may have 10 or more events that can be causes. A detailed analysis of an accident will normally reveal three cause levels:basic,indirect,and direct. At the lowest level, an accident results only when a person or object receives an amount of energy or hazardous material that
10、cannot be absorbed safely. This energy or hazardous material is the DIRECT CAUSE of the accident. The direct cause is usually the result of one or more unsafe acts or unsafe conditions, or both. Unsafe acts and conditions are the indirect causes or symptoms. In turn, indirect causes are usually trac
11、eable to poor management policies and decisions, or to personal or environmental factors. These are the basic cause.In spite of their complexity, most accidents are preventable by eliminating one or more causes. Accident investigations determine not only what happened, but also how and why. The info
12、rmation gained from these investigations can prevent recurrence of similar or perhaps more disastrous accident. Accident investigations are interested in each event as well as in the sequence of events that led to an accident. The accident type is also important to the investigator. The recurrence o
13、f accident of a particular type or those with common causes shows areas needing special accident prevention emphasis.2. Investigative ProceduresThe actual procedures used in a particular investigation depend on the nature and results of the accident. The agency having jurisdiction over the lacation
14、determines the administrative procedures. In general, responsible officials will appoint an individual to be in charge of the investigation. An accident investigation should use most of the following steps:·Defined the scope of the investigation.·Select the investigation. Assign specific t
15、asks to each (preferably in writing).·Present a preliminary briefing to the investigating team.·Visit and inspect the accident site to get updated information.·Interview each victim and witness. Also interview those who were present before the accident and those who arrived at the sit
16、e shortly after the accident. Keep accurate records of each interview. Use a tape recorder if desired and if approved.·Determine the following:·What was not normal before the accident.·Where the abnormality occurred.·When it was first noted.·How it occurred.·Determine t
17、he following:·Why the accident occurred.·A likely sequence of events and probable causes ( direct, indirect, basic ).·Alternative sequences.·Determine the most likely sequence of events and the most probable causes.·Conduct a post-investigation briefing.·Prepare a summa
18、ry report including the recommended actions to prevent a recurrence. Distribute the report according to applicable instructions.An investigation is not complete until all data are analyzed and a final report is completed. In practice, the investigation work, data analyzed and report preparations pro
19、ceed simultaneously over much of the time spent on the investigation.3. Fact-FindingInvestigator collects evidence from many sources during an investigation, gets information from witnesses and observation as well as by reports, interviews witnesses as soon as possible after an accident, inspects th
20、e accident site before any changes occur, takes photographs and makes sketches of the accident scene, records all pertinent data on maps, and gets copies of all reports. Documents containing normal operating procedures flow diagrams, maintenance charts or reports of difficulties or abnormalities are
21、 particularly useful. Keep complete and accurate notes in a bound notebook. Record pre-accident conditions, the accident sequence and post-accident conditions. In addition, document the location of victims, witnesses, machinery, energy source, and hazardous materials.In some investigation, a particu
22、lar physical or chemical law, principle, or property may explain a sequence of events. Include laws in the notes taken during the investigation or in the later analysis of data. In addition, gather data during the investigation that may lend itself to analysis by these laws, principles, or propertie
23、s. An appendix in the final report can include an extended discussion.4. InterviewIn general, experienced personnel should conduct interviews. If possible, the team assigned to this task should include an individual with a legal background. After interviewing all witnesses, the team should analyze e
24、ach witness statement. They may wish to re-interview one or more witnesses to confirm or clarify key points. While there may be inconsistencies in witnesses statement, investigators should assemble the available testimony into a logical order. Analyze this information along with data from the accide
25、nt site. Not all people react in the same manner to a particular stimulus. For example, a witness within close proximity to the accident may have an entirely different story from one who saw it at a distance. Some witnesses may also change their stories after they have discussed it with others. The
26、reason for the change may be additional clues.A witness who has had a traumatic experience may not be able to recall the details of the accident. A witness who has a vested interest in the result of the investigation may offer biased testimony. Finally, eyesight, hearing, reaction time, and the gene
27、ral condition of each witness may affect his or her powers of observation. A witness may omit entire sequences because of a failure to observe them or because their importance was not realized.5. Report of InvestigationAs noted earlier, an accident investigation is not complete until a report is pre
28、pared and submitted to proper authorities. Special report forms are available in many cases. Others instances may require a more extended report. Such repots are often very elaborate and may include a cover page, title page, abstract, table of contents, commentary or narrative discussion of probable
29、 causes, and a section on conclusions and recommendations.Accident investigation should be an integral part of your written safety and health program. It should be a formal procedure. A successful accident investigation determines not only what happened, but also finds how and why the accident occur
30、red. Investigations are an effort to prevent a similar or perhaps more disastrous sequence of events. You can then use the resulting information and recommendations to prevent future accidents.Keeping records is also very important to recognizing and reducing hazards. A review of accident and injury
31、 records over a period of time can help pinpoint the cause of view of accidents. If a certain worker shows up several times on the record as being injured, it may indicate that the person is physically unsuited for the job, is not properly trained, or needs better supervision. If one or two occupati
32、ons experience a high percentage of the accident in a workplace, they should be carefully analyzed and countermeasures should be taken to eliminate the cause. If there are multiple accident involving one machine or process, it is possible that work procedures must be changed or that maintenance is n
33、eeded. Records that show many accidents during a short period of time would suggest an environmental 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. Anal
34、ysis 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
35、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
36、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
37、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.
38、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
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