Document 17Dx6Ya2xz8DErednrNDZK7m

This chapter deals with costs of non-injury accidents, as well as injury accidents Theiefore the term "accident" is used in its broadest sense to cover occurrences, and their causes, which may lead to property damage and woi k injuries Accident investigation and Analysis Successful accident prevention requires a minimum of four fundamental activities 1. A study of all working areas to detect and eliminate or control physical or envuonmental hazards which contribute to acci dents 2 A study of all operating methods and prac tices 3 Education, instruction, training, and disci pline to minimize human factors which contribute to accidents 4 For cause analyses, a thorough investiga tion of at least every accident which re sults in a disabling injury (under ANSI Z16 I) or OSHA lost workdays to deter mine contributing circumstances Acci dents that do not result in personal injury (so-called "near-accidents" or "nearmisses") are warnings They should not be ignored This fourth activity, accident investigation and analysis, is a defense against hazards that are overlooked m the first three activities, those that are not obvious, or hazards that are the result of combinations of circumstances that are difficult to foresee Accident investigation and analysis is one of the means used to prevent accidents As such, the investigation or analysis must pro duce information that leads to countermeasures which prevent or reduce the number of acci dents The more complete the information, the easier it will be for the safety professional to design effective countermeasures For ex ample, knowing that 40 percent of a plant's accidents involve ladders is not as useful as knowing that 80 percent of the plant's ladder accidents involve broken rungs A good recordkeeping system, as discussed in Chapter 6, is essential to accident investiga tion m that it allows the basic facts about an accident to be recorded quickly, efficiently, and uniformly An investigation of at least every ANSI Z16 1 disabling injury or every OSHA lost workday case should be made Accidents resulting m nondisabling injuries, or no injuries, and also "near-accidents," should be investigated if time and facilities permit, especially if there is frequent recur rence of certain types of nondisabling mjunes, or if the frequency of accidents is high m certain aieas or operations For purposes of accident prevention, investi gations must be for fact-finding, not fault finding, otherwise, they may do more harm than good This is not to say that responsibil ity may not be fixed where personal failure has caused injury, or that such persons should be excused from the consequences of their ac tions What this does mean is that the investi gation itself should be concerned only with facts The investigating individual, board, or committee is best kept free from involvement with the punitive aspects of their investigation Types of investigation and analysis There are a variety of accident investigation and analysis techniques available to the in vestigator Some of these techniques are more complicated than others The choice of a particular method will depend upon the pur pose and orientation of the investigation The Failure Mode and Effect approach discussed in Chapter 4 could be very useful for investi gating situations where large complex and interrelated machinery and procedures are in volved, but may be of limited value in the investigation of accidents involving hand tools If management procedures and communica tions and their relationship to accidents are of great interest, the Management Oversight and Risk Tree analysis (MORT, see references at the end of Chapter 4) could prove to be very helpful The accident investigation and analysis pro cedure explored in this chapter is based upon the ANSI Z16 2 Standard, and focuses prima rily on unsafe acts and unsafe conditions, and is the most often used technique Other simi lar techniques involve investigation within the framework of defects in man, machine, media, and management (the "4 M's"), or education, enforcement, and engineering (the "3 E's") For analysis purposes, these techniques involve 151