Ships in Service Training Material 2009 Past theory accident causation Contemporary theory...

Ships in Service Training Material

2009

Past theory accident causation

Contemporary theoryexplaining accidents

Theories of Accidents

- Unsafe Acts (83%)- Unsafe Conditions (15%)- Acts of God (2%).

Events have bothphysical and

human elements often bound

together.

Heinrich 1930s

Ships in Service Training Material A-M CHAUVEL

Investigation of "near miss" incidents may identify potential causesand precautions needed.

Theory of Accidents - The Iceberg


1 death 10 minor injuries

30 property damage

600 incidents.

Incident/Accident

Human errors


Error

IntentionIncorrect

IntentionCorrect

Lapse

Slip

Mistake

Violation

Human Errors


2

3

1

Occupational psychologists have shown that there are only a limited number of types of errors:

1- Slip or Lapse : Is an error which occurs during the process of carrying out a plan of action. - a slip is link to the execution. - a lapse is link to the memory of the information.

Human Errors


Occupational psychologists have shown that there are only a limited number of types of errors :

An example would be when you drive your usual route when you had the intention of going somewhere else.


2- Mistake : Is an intentionally error carried out during the selection of an action or in the means to carry it out.

3- Violation : Is an voluntarily error carried out when it is known to be contravening an established code or rule.

Human Errors Occupational psychologists have shown that there are only a limited number of types of errors :

IntentionIncorrect

A second type of classification system considersthe mental functions context in whichthe error is based on :

Human Errors


Skills Rules

Knowledge

http://larryshomeport.com/Trident.jpg

Ships in Service RANDY GLASBERGEN

Human Errors

Occurs during

performance

of a well known

routine task.

1- Skills Based :

We don’t need to worry about securitymost of our written procedures

are impossible to understand in the first place.

Ships in Service RANDY GLASBERGEN

Human Errors

Occurs when the action is governed byrules or operating instructions.

2- Rules Based :

Occurs when a person

must apply

knowledge and experience

to work out

the correct action

in a set of circumstances

which are usually unusual.

Human Errors


3- Knowledge Based :

Error

IntentionIncorrect

IntentionCorrect

Lapse

Slip

MistakeRules-basedMisapplication

Bad rule

Memorial failureForgetting intentions

Losing placeOmitting planned item

Violation

Knowledge-basedRoutine

ExceptionalSabotage

Failure in attentionOmissions, Intrusions

DisorderingMistiming

Skills-based

Human Errors



1.0 Provide first aidand medical care

to injured person (s)2.0 Report Incident

occurrence to adesignated person

3.0 Investigate the

incident /accident

4.0Identify the causes

5.0 Report the findings

6.0 Recommend a plan for corrective action

7.0 Implement the plan

8.0 Evaluate theeffectiveness of

the corrective action

9.0 Make changes for continuous

improvement


ProcessIncident - Accident Investigation

Process

1.0 Provide first aidand medical care

to injured person (s)


Incident - Accident Investigation

- Rescue operations… - Medical treatment of the injured... - Prevention of further injuries…

have Priority.

Others activities must not interfere with these matters. When these matters are under control, the investigators can start their work.

Injured Person (s)The most important immediate actions :


Process

2.0 Report Incidentoccurrence to a

designated person



Reporting IncidentsISM Code Section 9.1


“The SMS should include procedures ensuring that non-conformities, accidents and hazardous situations are : - Reported to the company,- Investigated and- Analysed with the objective of improving safety and pollution prevention”

http://www.imo.org/Publications/index.asp?topic_id=424

Reporting Incidents


1 - Employee Supervisor Initial Report

3 - Employee Supervisor Final Report

2 - Investigation Report

Example

Employee Supervisor Initial Report


Company / Ship Name :

Date : By :

Name of Employee : Job Title :

Time & Date of Injury :

Date Reported : To Whom :

Where did Injury Occur :

How was Employee Injured :

Nature of Injury (Be Specific) :

Recommended Safeguards to Prevent Similar Occurrences:

Corrective Actions Taken to Prevent Recurrence of this Type of Accident :

Supervisor Initial Report


TREATMENT ACTION TAKEN (Check all that apply) :

O Lost Time

O Hospital Care

O Recorded Only

O Doctor’s Care

O First Aid

Name of Doctor : Name of Hospital :

Signature of Supervisor :

NOTE: Supervisors must advise employees that a Doctor’s note is needed if employee is going to be out of work. Also, a note is needed upon returning to work. These notes should state the reason for being out of work and the time frame. Doctor’s notes and Supervisor’s Report of Injury should be turned in to the Human Resources Dept. Employee remarks :

Date : Employee :

I have read the above statement and find it to be true and correct to the best of my knowledge

Supervisor Initial Report


Example

Employee Supervisor Final Report


Name of Employee :

Date of the Injury : Date Reported :Time :

Please describe clearly how the accident/injury occurred :

Were there witnesses? O Yes O No (Note: If yes, attach witness statements)

Please list the name of any witnesses:

Was medical attention needed? O Yes O No

If yes, where did the employee receive treatment and what type of treatmentdid he / she receive?

O a.m. O p.m.

Supervisor Final Report



:

What time did the employee’s shift start ? O a.m. O p.m.

Did the employee leave work early after the injury ? O Yes O No

At what time did the employee leave ? O a.m. O p.m.

Will the employee lose time from work as a result of the injury ? O Yes O No

What acts, failures to act and/or unsafe conditions contributed most directly to thisaccident/injury (immediate cause) :

What actions do you recommend should be taken to prevent recurrence of a similaraccident / injury :

Additional comments :

Supervisor’s Signature Date: Time:


Please describe the type of discomfort you are feeling :

Do you feel any discomforts? O Yes O No

Please identify the area in which you received an injury and any areas where you are receiving pain :

Do you have any suggestions to prevent this accident from recurring?

To be completed by the employee

and added to your report


Employee Signature Date: Time:

Example

In Port


Any accidentmust be reported

Inform thesupervisor

Person / Witness

Evaluate theaccident

Supervisor

Serious injury

No

Yes Call the medicalemergency service

Supervisor

Issue the accidentreport form 1Supervisor

Accident reportPart 1

Accident report

Yesor No

Make the investigationSenior Engineer.

Maintenance (SEM)

Issue the accidenton report form 2

SEM.

Accident reportPart 2

Accidentfile

Alwaysapply Fist Aidwhen possible

Within 24 hours

Marineaccident

No

Make the investigationHarbour Master

Issue the accidenton report form 2Harbour Master

Accidentinvestigation

report

Yes

and

The final report must be returnedto Secretary within 24 hours of the

date of Accident

How and when to issuedan accident report(People Injured )

ACCIDENT REPORT - Part 1 - Notification

Notification to be returned to Secretary within 24 hours of date of Accident

Occupation: ( State whether full-time or Temporary )Age : years ( To be filled in by the Secretary’s Department

) Address :

Accident

Date & Hour of Accident( day, month, year, hour, a.m / p.m ) :

Where did the accident happen :

- a) Upon what date did you receive notice of the accident :- b) From whom :Did she/he continue working : YES NO if no fill in the next line

- Date and time she/he ceased work ( day, month, year, hour, a.m / p.m ) :

Injured person ( Full Name ) :

Report N° :

Cause of the injury :

Reason of the accident :

Nature of accident : ( Describes injuries, in cases of eyes/limbs state left or right )

Injured person treated at :

Was she/he detained : YES NOAccident witnessed by Name(s) :

Describe work being done :

- Date of resuming work and Signed (Foreman or Supervisor ) :

- Date and Countersigned ( Head of Department ) :

- Date and Countersigned ( Company Secretary ) :

ACCIDENT REPORT - Part 1 - Notification

Notification to be returned to Secretary within 24 hours of date of Accident

Report N° :

ACCIDENT REPORT - Part 2 - Investigation

Investigation to be returned to Secretary

Date & Hour of notification of accident :( day, month, year, hour, a.m / p.m )

Investigation of accident

Accident Investigation Report prepared by :- Date and Signed (Senior Engineer Maintenance

or Harbour Master ) :

Completed Report received by :- Date and Signed ( Company Secretary ) :

Date & Hour of notification of accident :( day, month, year, hour, a.m / p.m )

Report N° :

Example

In Shipping Company


General Information Vessel / Office:

Report date : Author’s name :

Report N°

Date of the Event : Local time of the Event :

Vessel Position : Attachments :

Report type Fatality:Near AccidentIllness Accident


Safety & Improvement ReportAccident / Near Accident and Illness

EventName of person (s) :

Description of the Event :

Restricted Work Case :

Lost time injury :

Medical treatment :

Transfer to Hospital at next Port : Transfer to Hospital by Helicopter :

Other :



Causes

Description of the immediate cause :

Human error : Unknown :

Technical : Procedure :


Description of the root causes ( if possible ) :


Immediate Remedial Actions Carried out

Description of the actions taken at the time of the event :

Suggestions to avoid reoccurrence Propositions for Corrective and Preventive Actions :



Process

3.0 Investigate the incidentor accident



Investigate the incident

After injuries, have been treated or medical care obtained. - Assess the scene for hazards.

- Report it and begin the investigation.

It is advisable for assigned investigators not to be given emergency tasks following an incident so that they can concentrate on the investigation.

Initial response



- Inspect the scene for any hazards that could cause more damage.

- Keep everyone away from the immediate area so the scene remains undisturbed until evidences have been collected.

- Take steps to preserve evidences. - Identify and make a list of all witnesses.

Secure the scene

S.ISIK



- Keep an open mind. If you think you already know what happened and why, you might overlook something really important. - Facts should be separated from “opinions”. - Record what people actually saw or experienced,

not what someone “thinks” happened, or what someone else “said” happened.

Collect the FactsInvestigation Process

A-M CHAUVEL


- Consider all possible causes.

- Make notes of ideas as they occur, but don’t draw conclusions until all the information is gathered.

- The purpose of the investigation is to :

- Find the facts, (Objectives evidences) - Prevent this event from happening in the future.

Collect the FactsInvestigate the incident

A-M CHAUVEL

What means an Objective Evidence ?


ObjectiveEvidence

“ Objective evidence consists of qualitative or quantitative

information, records, or statements of fact pertaining to

the characteristics of an item or service or to the existence and

implementation of a process element.

It is based on observation,measurement or test and can be verified.”

See moduleObjective Evidence

IncidentIncidentAccidentAccident

WHEREWHEREWHATWHATWHATWHAT WHENWHENWHENWHEN

WHYWHYWHYWHYHOWHOWHOWHOW WHOWHOWHOWHO

Objective Evidences


MaterialWork &

Task

People

ManagementSystem

Environment

Management Oversight and Risk Tree Ships in Service Training Material A-M CHAUVEL


See module

IMO Resolution A 884 (21)

Guideline for the Investigationof Human Factors

in marine casualties and incidents


Topics to be cover


Humanfactors

Organizationon board

Working andliving conditions

Shipfactors

Shore sidemanagement

External influencesand environment

Working and living conditions

- Level of automation.

- Ergonomic design of working, living and

recreational areas and equipment.

- Adequacy of living conditions.

- Opportunities for recreation.

- Adequacy of food.

- Level of ship motion, vibrations,

heat and noise.

Topics to be cover


Organization on board

- Division of tasks and responsibilities.

- Composition of the crew.

- Manning level.

- Work load / complexity of tasks.

- Working hours / rest hours.

- Procedures and standing orders.

Topics to be cover


Organization on board

- Communication Internal & External.

- On-board management and supervision.

- Organization on-board of training & drills.

- Teamwork including

resource management.

- Planning (voyage, cargo, maintenance).

Topics to be cover


Ship factors

- Design.

- Work load / complexity of tasks.

- State of maintenance

- Equipment (availability, reliability).

- Cargo characteristics, including

securing, handling & care.

- Certificates.

Topics to be cover


External influences and Environment

- Weather and sea conditions.

- Port and transit conditions

(VTS, pilots…)

- Traffic density.

- Ice conditions.

- Organizations representing shipowners

and seafarers.

- Regulations, surveys and inspections

( International, national, port,

classification societies,…)

Topics to be cover


Shore side management

- Policy on recruitment.

- Safety policy and philosophy.

- Management commitment to safety.

- Scheduling of leave periods.

- General management policy.

- Port scheduling.

- Contractual and / or industrial

arrangements & agreements.

- Assignment of duties.

- Ship-shore communication.

Topics to be cover


Human factors

- Ability, Skills, Knowledge.

- Personality.

- Physical condition.

- Activity prior to accident / occurrence.

- Assign duties at time of the event.

- Actual behavior at time of the event.

- Attitude.

Topics to be cover


Incident/Accident Investigation

Areas of Human factors inquiry



S. ISIK

Skilful questioning can help the investigator eliminate irrelevant lines of inquiry and focus on areas of greater potential significance.

It may be necessary to : - Verify, - Cross-check or - Augment information received from one person by interviewing others on the same points.




Two Issues ( see Appendix 2 – Res.884)

Shipboard

Shore-side management

Areas of Human factors inquiryShipboard Issues

S. ISIK

1- Safety policy.2- Activity prior to the event.3- Duty at the time of the event.4- Actual behavior at time of the event.5- Training/ education/ professional experience.6- Physical condition.7- Psychological, emotional, mental condition and employment conditions.8- Workload/complexity of tasks.


Areas of Human factors inquiryShipboard Issues

S. ISIK

9- Work-period/ rest-period/ recreational pattern.10- Relationship with other crew members and superiors/ subordinates.11- Living conditions and shipboard environment.12- Manning levels.13- Master’s stranding orders.14- Level of automation/ reliability of equipment.15- Ship design, motion/ cargo characteristics.


Areas of Human factors inquiryShore-side management Issues

16- Scheduling of work and rest periods.17- Manning level.18- Watchkeeping practices.19- Assignment of duties.20- Shore-ship-shore support and communication.21- Management policies.22- Voyage planning and port call schedules.23- Recreational facility.24- Contractual and/ or industrial arrangements and agreements.25- National/ International requirements.


Common Human Element termsDefinitions ( see Appendix 3 – Res.884)


Diminished Human Performance

MarineEnvironment

SafetyAdministration

Management Mental Action


Diminished Human Performance

MarineEnvironment

SafetyAdministration

Management Mental Action

What can be the root cause ?

Common Human Element termsDefinitions ( see Appendix 3 – Res.884)

Common Human Element termsDiminished Human Performance

Deliberate misaction Excessive workload

Mental/physicalillness

Visual problem

Lack of self-discipline

Low morale

FatigueDiminished motivation

Alcohol/Druguse

InjuryEmotional

Inattention

Panic

Anxiety

Personal problem

Mental impairment


Common Human Element termsMarine Environment

Poor maintenance

Hazardous natural environment

Poor human factor design

Poor operations


Common Human Element termsSafety Administration

Inadequate languageskills

Inadequate knowledgeof ship operations

Inadequate technical knowledge

Unaware of role/taskresponsibility

Inadequate situational communication/awareness

Inadequate knowledge

of ship procedures

Lack of communicationor coordination

Inadequate knowledge of

regulations/standards


Common Human Element termsManagement

Poor regulations, policies,procedures or practices

Poor job design

Inadequatemanpower available

Inadequate manning

Failure to maintain discipline

Inadequate managementof physical resources

Misapplication of good regulations,policies, procedure or practices

Failure of command

Inadequate supervision

Inadequateco-ordination

or communication


Common Human Element termsMental Action

Incorrect identification

of a signal

Lack of situational awareness

Lack of perception

Incorrect recognitionof a signal




- Expert in incident causation

experienced in investigative techniques.

And fully knowledgeable of the :

- Work processes. - Procedures, persons. - Industrial relations environment of a particular situation.

Who should conduct an Investigation ?


An investigation should be conducted by :

Unfortunately, such persons are hard to find.

Especially in smaller organizations,

both workers and supervisors with little, if any,

previous investigative experience may be called upon to participate in an

incident investigation.

Who should conduct an Investigation ?


Are Investigators Impartial ?An investigator who believes that incidents

are caused by :

unsafe conditions will likely try to uncover

working conditions as causes.


unsafe acts will attempt to find the

human errors as causes.

An “ investigation " which concludes that an incident was due to worker carelessness,

and goes no further, fails to seek answers to several important questions such as :

- Was the worker trained ? If not, why ?

- Was the worker distracted ? If yes, why ?

- Was a safe work procedure being followed ? If not, why ?

- Were safety devices in order ? If not, why ?


Are Investigators Impartial ?

http://wiki.ehow.com/

Answers to those related questions will probably help

to reveal the “root causes”

conditions of the incident for real action.


Are Investigators Impartial ?


Investigation : Some Tools


Tools for investigation to be immediately available : - pencil, - paper, - camera, - film, - camera flash, - tape measure, etc…

http://geektechnique.org/images/infrared-camera-1.jpg

http://www.st-armand.com/Photos/Tablettes-01.jpg



Eyewitnesses Interview


Purpose

S.ISIK

The purpose of interviews is to :

- Establish an understanding

with each witness.

- Obtain in his or her own words

description of the event.


- Witnesses may be the primary source of information.

- Witnesses include :

- Injured or ill workers. - Nearby workers. - Pre-shift workers. - Supervisors. - Any workers in the area at the time.


S.ISIK

http://www.witness.org/

Every effort should be made to interview witnessesas soon as practicable after the incident.

Interviewing witnesses is probably one the hardest task facing an investigator.

Because witnesses may beunder severe emotional stress

or afraid to be completely open

for fear of recrimination :




individual perceptionsmay be lost in

the normal process ofaccepting consensus view

where doubt existsabout the facts.

Witnesses should be interviewed alone,rather than in a group.


Eyewitnesses InterviewIf witnesses have an opportunityto discuss the event among themselves,

- Establish the positions of each person involved. - Obtain a description of the event (s).

The decision may depend in part on the nature of the event and

the mental state of the witnesses.


But, it may be preferable to carry out interviews ina quiet office where there will be fewer distractions.

Eyewitnesses InterviewIt is reasonable to interview a witness atthe scene of the incident where it is easier to :

The questions asked to the witness will naturally vary with each event, but there are some general questions that should be asked each time :


- Where were you at the time of the event? - What were you doing at the time? - What did you see…you hear? - What were the environmental conditions (weather, light, noise, etc.) at the time? - What was (were) the injured worker (s) doing at the time? - In your opinion, what caused the event?


http://www.myspace.com/oldmastersnewvisions



“ Interviewing is an art that cannot be given justicein a brief document. ”

A few do's and don’ts can be useful…

What happened and Why. - Let the witness talk. - Listen to him. - Confirm that you have the statement correct. - Try to sense any underlying feelings of the witness. - Make short notes only during the interview. - Thank each witness.


Put the witness, who is probably upset, at ease andemphasize the real reason for the investigation is to determine :

Eyewitnesses Interview :

Do’s

- Intimidate the witness. - Interrupt him. - Prompt the interview. - Ask leading questions. - Show your own emotions. - Make lengthy notes while the witness is talking. - Ask questions that can be answered by simply "yes" or "no".


Eyewitnesses Interview :

Don’ts

Asking questions is a straightforward approach to establishing what happened.

Care must be taken to assess the credibility of any statements made in the interviews.

Answers to a first few questions will generally show how well the witness could actually observe what happened.

If the investigator was not at the scene at the time






An technique sometimes used to

determine the sequence of events is to replay them as

they happened.

A witness (usually the injured worker) is asked to reenact in slow motion the actions that preceded the accident.

Great care must be taken so that further injury or damage does not occur.


1

2



Penitentiary in Spain


Vision of ThingsVision of Things

?


Investigate the incident/accident


Physical evidence is probably the most non-controversial information available : - It is also subject to rapid change or obliteration. - It should be the first to be recorded.

Physical Evidence


In the case of an accident, some jurisdictions, required that the site must not be disturbed

without prior approval from appropriate government officials such as the:

Coroner, inspector or police.

Physical EvidenceBefore attempting to gather information :


- Examine the site for a quick overview.- Take steps to preserve evidence.- Identify all witnesses.

Based on the knowledge of the work process,check items such as :

Physical Evidence

- Positions of injured workers. - Equipment being used. - Materials being used. - Safety devices in use. - Position of appropriate guards. - Position of controls of machinery. - Damage to equipment. - Housekeeping of area. - Weather conditions. - Lighting levels. - Noise levels.


Physical EvidenceWhen possible, take photographs before anything is moved, both of the general area and specific items.

Even if photographs are taken,written notes about thelocation of these items

at the event sceneshould be prepared.



http://www.st-armand.com/Photos/Tablettes-01.jpg

Physical EvidenceWhen possible, take photographs before anything is moved, both of the general area and specific items.

Broken equipment, debris, and samples of materials involved may be removed for further analysis by appropriate experts.


Sketches of the event scenebased on measurements taken

may also help insubsequent analysis and

will clarify any written reports.


Physical Evidence

Physical Evidence


"TWA Flight 800"

Physical Evidence


Investigation Analysis

Similar Witness 2Witness 1

GunRed sport carEarly 40’sHeight : 5’10Cashier surrendered

KnifeRed OpelMid 30’sHeight : 6’Grabbedcash…

Time 2 pmShirt blackPants black

Light brown hatSunglassesHair blondeEthnicity :

White


Venn / Euler Diagram

Process

4.0Identify the causes





Identify the Causes


Identify the Causes

- What happened and - How it happened.

This has taken considerable effort to accomplish but it represents only the first half of the objective.

Now comes the key question is :Why did it happen?


Similar Witness 2Witness 1

GunRed sport carEarly 40’sHeight : 5’10Cashier surrendered

KnifeRed OpelMid 30’sHeight : 6’Grabbedcash…

Time 2 pmShirt blackPants black

Light brown hatSunglassesHair blondeEthnicity :

White

Identify the Causes At this stage of the investigator should know most of the facts about:

The key question : Why did it happen ?


To prevent recurrences of similarincidents, the investigator must find all possible answers to this question. He has to keep an open mind to - All possibilities and - Sought out all pertinent facts. There may still be gaps in the tracingof the sequence of events that resulted in the incident or accident.

Identify the Causes



The key question : Why did it happen ?Identify the Causes

The aim is to find answers to the question why to seeks both :

- Unsafe acts and unsafe conditions.

- Human failures and/or technology.

- The environment or their interface.

Some authorities claim that assumptions have no place in

accident investigations.

The key question : Why did it happen ?

On the other hand,it may better to record

assumptions basedon what evidence is

available, than to leave questions

unanswered.


Identify the Causes


Accident

IncidentIncident

PeopleWork

Processes/Tasks

Materials Environment

Safety Management

System

An incident or accident rarely has

a single cause.

There are generally

a number of

contributing factors.

Identify the Causes

S.ISIK

Is a difficult exercise


1 - Systematically review all the factors that could contribute to the event, including :

- Equipment. - Materials. - People. - Environment. - Work processes. - Tasks. - Management system.

Accident

IncidentIncident

PeopleWork

Processes/Tasks


Safety Management

System

Is a difficult exerciseIdentify the Causes

S.ISIK


2 - Check each factor against the facts to see if it could have played a role in the event.

3 - Reconstruct the sequence of events leading to the accident and check potential causes at each step.

Accident

IncidentIncident

PeopleWork

Processes/Tasks


Safety Management

System

Is a difficult exerciseIdentify the Causes

S.ISIK

The key question : Why the event happen ?

The investigator :

- May need to re-interview some witnesses to fill these gaps,

or

- May have to resort to assumptions.


Identify the Causes



Identify the Causes

After gathering all the facts the investigation team needs

to evaluatethe factors concerned andisolate the key factors of

“ Why the event occurred. ”

The approach is relatively simple, by asking the question:

“ Would the event have occurred

if this particular factor was not present ? ”

Contributing Factors

http://nvizx.typepad.com/.shared/image.html?/photos/uncategorized/palousefalls.jpg

Direct causes usually occur immediately before the event such as

Unsafe Behaviors or Hazardous Conditions.

Hazardous Conditions

- Inadequate or broken equipment.- Gas leak.- Poor maintenance conditions.- Poor housekeeping.

Unsafe Behaviors

- Improper lifting.- Failure to wear Personal Protection Equipment.- Improper use of equipment.- Driving too fast.

Direct causes


Identify the Causes

S.ISIK


Identify the Causes

A-M CHAUVEL

IncidentDirectcause

Unsafe behaviorsHazardous conditions

Most Hazardous Conditionsare the result

of Unsafe Behaviors.

Individual Unsafe Behaviors may occur at any level of

the organization.

Unsafe Behaviors & Hazardous Conditions


Identify the Causes

S.ISIK

- Failing to comply with rules.- Using unsafe methods.- Taking shortcuts.- Horseplay.- Failing to report injuries.- Failing to report hazards.- Allowing unsafe behaviors.- Failing to provide training.- Failing to supervise.- Failing to correct.- Scheduling too much work.- Ignoring crew stress.

Example of Unsafe Behaviors include :


Identify the Causes

S.ISIK


Identify the Causes

A-M CHAUVEL

IncidentIndirect

Cause (s)Directcause

Surface Factors

Job FactorsPersonal Factors


Indirect causes give rise to :

- Unsafe or - Sub-standard practices and conditions, but they are not the beginning of the cause and effect sequence.

Indirect causes

Indirect causes set the stage for the incident or accident. They are the real reasons or causes for - Unsafe Behaviors or - Hazardous Conditions.


Identify the Causes

S.ISIK

Personal Factors

- Lack of knowledge.- Lack of skill.- Lack of motivation.- Physical or psychological stress.- Inadequate physical ability.- Impairment (fatigue, substance abuse).

An indirect cause is generally categorized into 2 groups :


Identify the Causes

S.ISIK

Job Factors

- Inadequate tools and equipment.- Inadequate engineering.- Inadequate work procedures.- Inadequate maintenance.- Inadequate purchasing.- Inadequate leadership or supervision.

An indirect cause is generally categorized into 2 groups :


Identify the Causes

S.ISIK


Identify the Causes

A-M CHAUVEL

IncidentIndirect

Cause (s)Directcause

RootCauses

True Factor

System weaknessesSystem implementation weaknesses

Job FactorsPersonal Factors


Surface Factors

The technique is based on a fault tree analytical method,

where the top eventis the event.

The causes of the incident

or accidentare identified by asking the why questions until they become absurd.

Why…?Where arethe roots


Root Cause AnalysisIdentify the Causes

Failure to identify the root cause will allow events to continue.



Identify the Causes

S.ISIK

Root Causes underlie all other causes :

- - Lack of employee orientation.

- Weakness in the Health and Safety program.

- Equipment design flaws.

- Lack of resources.

For example : If a direct cause of the eventis identified as a missing guard.

- one of the indirect causes could be poor maintenance. - one of the root causes could be the lack of a maintenance program.



Identify the Causes

S.ISIK

Root Causes lie within the supervisory / management realm.

Root Causes may be separated into two categories :

Normally defects in implementation represents ineffective management of the Safety Management System.


Identify the Causes

S.ISIK

System weaknesses :

System implementation weaknesses :

Missing or inadequately prepared policies, programmes, plans, processes and procedures will affect conditions and practices on board. Defects in system preparation represent hazardous system conditions.

Failure to initiate, carry out, or accomplish safety policies, programs, plans, processes, and procedures.

System weakness and System implementation weaknesses can be :

- Missing or inadequate safety policies / rules.

- Training program not in place.

- Poorly written plans or procedures.

- Inadequate processes.

- No procedures in place.

- Safety policies or rules not being enforced.

- Safety training not being conducted.

- Adequate supervision not conducted.

- Incident/accident analysis inconsistent.

- Procedures not reviewed periodically.


Identify the Causes

S.ISIK

PIPER ALPHA

Destroyed by a fireWednesday 6 July 1988

North Sea


Identify the Causes

Just to re

member


There is less pressure on companiesin investigating near-misses soit gives an ideal opportunity to improve safety before any disaster is allowed to happen.

Investigate “near-misses”Identify the Causes

S.ISIK

- Encapsulate valuable information.

- Their potential are not realised.

- Often go unreported.

- Staff are discouraged from reporting : - Fear of blame. - Complexity of the reporting system.

Or simply : “ I forgot to fill up the report.”

Near-Misses



Investigate “near-misses”Identify the Causes

A-M CHAUVEL

It is far easier to get everyone to approach “near-misses” investigations as opportunities for improvement rather than assessments for blame.

Generally people feel more comfortable telling the real and complete story in a near- misses situation, it makes it easier in these investigations to get to the true causes of problems.


Process

5.0 Report the findings




Report the findingsInvestigation Report

S.ISIK

Having investigated and analyzed the incident/accident,

it must now be reported.

Writing the event in a report formis the way of communicating

the incident/ accident to all the concerned parties.

In few years time much of the details of the incident/accident will have been forgotten, except perhaps for the direct victims of the accident.

What will be remembered is the report, as we can still access it as needed.

Reporting is the key to benefiting from the findings and recommendations of an investigation.

Ships in Service Training Material S.ISIK

Report the findingsWhy

Reports should be prepared as soon as the investigation is complete and distributed to the concerned parties.

Company should encourage investigators to use standard reporting format and incorporate a model report in the procedures.


Report the findings

S.ISIK

The report should give background informationon the event and enable the reader to reach similar conclusions to the investigator.

2 - Investigation Report Example

Report the findings


1. Employee : 2. Date of Birth : 3. Date of Report :

4. Street Address :

5. Job Title : 6. Location of Accident :

7. Time of Accident : 8. Date of Accident : 9. Day of Week :

10. Sex : O Male O Female

11. Injury Requiring : O First Aid O Out-Patient O Hospitalization

12. Safety Inspector 13. General Superintendent

AN ACCIDENT IS A MISHAP OR UNINTENDED EVENT GENERALLY CAUSED BY AN UNSAFE ACT OR UNSAFE CONDITION OR A COMBINATION OF THE TWO. EACH ACCIDENT, REGARDLESS OF WHETHER IT RESULTS IN AN INJURY, PHYSICAL DAMAGE, OR NEAR-MISS, SHOULD BE INVESTIGATED TO SEEK THE CAUSE AND TO TAKE PROPER CORRECTIVE ACTION TO PREVENT RECURRENCE. THE ACCIDENT SHOULD BE INVESTIGATED BY THE INJURED EMPLOYEE’S GENERAL FOREMAN. IT SHOULD BE CONDUCTED ON THE DAY THAT THE ACCIDENT OCCURRED. YOUR PURPOSE IS TO GAIN FACTS AND ACCURATE ACCOUNTING FROM THE INJURED PARTY AND WITNESSES. YOUR PURPOSE IS NOT TO PLACE BLAME. THIS REPORT CANNOT BE CONSIDERED COMPLETED UNTIL THE SUPERVISOR HAS INDICATED WHAT CORRECTIVE ACTION HAS BEEN TAKEN OR WILL BE TAKEN TO PREVENT A RECURRENCE.

Investigation Report ( Part One )


Company Policy

14. Employee’s Job or Activity at Time of Accident including tools, equipment, and environment conditions :

15. Accident Type :

16. Nature of Injury :

17. Part of Body :

18. Provide a description of the accident. Also the name (s) of the object, substance, or exposure which directly brought about the injury. Please include the name of all witnesses

Names of Witnesses :

Names of Witnesses :


Investigation Report ( Part One )

Checklist forAccident Investigation Report

Example


Accident Investigation Report

· Operating equipment/tools at unsafe speeds? · Taking an unsafe position? · Distracted through horseplay, practical joking, quarreling, fighting, startling act of another employee?

. Did the employee have : - The skills to do the job? - The physical and mental ability to do the job?

14.a The person

· Placed on the right job? · Properly trained for the job?

· Experienced in the job? · Tired, using medication, drinking, or taking drugs?

· Under emotional stress, worried, or having distracting personal problems?

Was the employee :


ChecklistAccident Investigation Report

14.b The Tools & Equipment

· Working properly? · Adjusted correctly? · Was it the right tool or machine for the job? · Was it properly guarded, with guards adjusted and working correctly? · Was the stock or material correct and positioned correctly? · Was the tool in proper condition?

Was the machine :14.c The Environment

Was the area :

· Well lighted? · Too hot or too cold? · Crowded or congested?

. Noisy, or were vapors, smoke, etc. present to be distracting? · Did the noise, smoke, vapors, etc. resent a health hazard? · Was the floor surface in good condition and clean?


Accident Investigation Report

Absorption (skin contact)

Assault

Caught in/on/between

Contact with electricity

Explosion

Exposure to radiation

Exposure to temperature extremes

(burns, scalding, freezing,

heat exhaustion, sunstroke)

Ingestion (swallowing)

Inhalation (breathing)

15. The Accident Type

Overexertion (lifting)

Overexertion (reaching, pushing,

pulling, bending)

Repeated trauma (noise, vibration)

Repetitive motion

Slip, trip, fall – different level

Slip, trip, and/or fall – same level

Struck against

Struck by falling, sliding, or

moving object (s)

Struck by flying objects


ChecklistAccident Investigation Report


16. The Nature of Injury

Amputation (all injuries other than spinal cord)Angina pectoris (chest pain)BurnConcussion (head injury)Contusion (bruise)CrushingDislocationElectric shockEnucleation (removal of the eyeball)Foreign bodyFracture FreezingHearing loss traumatic

Heat prostration HerniaInfectionLacerationMyocardial infarction (heart attack)PunctureRuptureSeverance (for spinal cord only)SprainStrainVascularVision lossSuffocationAsphyxiaHeadacheNauseaDust disease

AsbestosisBlack lungByssinosisSilicosisRespiratory disorders (gases, fumes, chemicals, etc.)Poisoning (chemical)Poisoning (metal)DermatitisMental disorderRadiationLoss of hearingContagious diseaseCancer

Other injuries


17. Part of the Body

Multiple Head InjurySkullBrainEar (s)Eye (s)NoseTeethMouthOther Facial Soft TissueFacial BonesMultiple Neck InjuryVertebraeDiscSpinal CordLarynx

Soft Tissue – Neck AreaTracheaMultiple Upper ExtremitiesUpper Arm (including clavicle & scapula)ElbowLower ArmWristHandFinger (s)ThumbMultiple TrunkUpper Back Area Low Back AreaDisc

Chest - including ribs sternum, soft tissueSacrum & CoccyxPelvisSpinal CordInternal OrgansHeartMultiple Lower ExtremitiesHipThigh KneeLower LegAnkleFootToe(s)Multiple Body Parts

:

Company Name ( If external Safety Inspector )

Name : Date of accident :

Type of work being done : How long so employed ?

Date accident reported :Department name : Immediate supervisor :

CAUSE of injury (state what happened; give machines, materials, etc. involved; all details):

State injury caused by above : By whom ?

First aid given?

Other treatment (describe) :

What is necessary to prevent similar accident ?

What action, and by whom, has been taken ?

Other comments :

Signature of Safety Inspector Date :


Investigation Report ( Part Two )

:

Review by Safety CommitteeRecommendations :

Final Disposition :

Signature of Secretary : Date :

To be completed by the Safety Committee

and add to the Employee Supervisor Final Accident report


Investigation Report ( Part Two )

- The prepared draft of the sequence of the events can now be used to describe what happened.

- Readers of the report do not have the intimate knowledge of the incident/ accident that the investigator has. So, all pertinent details must be included. - Photographs and diagrams may save many words of description.


Report the findingsThe Written Report

http://curry.edschool.virginia.edu/go/edis771/fall99webquests/student/birdskwl.htm


- Identify clearly where evidence is based on : - Facts. - Eyewitness accounts. - Assumptions. - The reasons for the conclusions should be stated and followed by recommendations.

The measure of a good investigation report is quality,

not quantity. Ships in Service Training Material A-M CHAUVEL

Report the findingsThe Written Report

http://curry.edschool.virginia.edu/go/edis771/fall99webquests/student/birdskwl.htm


The written report should :


Report the findings

S.ISIK

- Be clear, concise and logical.

- Use photos and drawings to illustrate key points.

- Include such information as : - Summary giving basic facts of the event and stating whether there were injuries, deaths. - Damage to ship or the environment. - Ship particulars including name, type, gross tonnage etc... - Details of crew involved with their job titles, and location. - Date and time of the event.

- Description of what happened (from witnesses and crew involved) – this is easier to do using a single chronological order of the events.- Description of injury or illness.- Description of damage to the ship, equipment or the environment.- Causes of accident – including direct, indirect and root causes.

- Recommendations for corrective and preventive actions including who is responsible for implementation and by what date.


The written report should : Report the findings

S.ISIK

When a standard form is prescribed the investigator will have no choice for writing and presenting its report.

However he should be aware of, and try to overcome shortcomings such as if:


The written reportReport the findings

- If a limited space is provided for an answer, the tendency will be to answer in that space despite recommendations to “ use back of form if necessary.”



- If a checklist of causes is included, possible causes not listed may be overlooked.

- Headings such as “ unsafe condition “ will usually elicit a single response even when more than one unsafe condition exists. - Differentiating between “ primary cause " and “ contributing factors " can be misleading.



In the unlikely event that an investigator has not been able to determine the causes of an incident/accident with any certainty, he probably still has uncovered safety weaknesses in the operation.


It is appropriate that recommendationsbe made to correct these deficiencies.


Process

6.0 Recommend a plan for corrective action




Recommend corrective action

S.ISIK

This is the most important part of the report:

- Recommended corrective action should make it very difficult, if not impossible for the event to happen again.

- Recommend appropriate control of hazards through:

- Engineering, - Administrative or - Personal Protective Equipment controls.

When the analysis is completed, build a step-by-step account of what happened working back from the moment of the event, listing all possible causes at each step.


What should an Investigator knows when making the conclusions ?

WHYHOW


Each conclusion should be checked to see if it is supported by objective evidence (s): - Direct (physical or documentary). - Eyewitness accounts. - Assumption.


What should an Investigator knows when making the conclusions ?


A difficulty that has bothered many investigators

is the idea that no one wantto be blame.

What should be done if the investigation reveals"human error"?


However, when an investigation reveals that some person (s) among management,

supervisor and the workerswere apparently at fault,

this fact should be pointed out.


Failing to point out human failingsthat contributed to an event will :

- Not only downgrade the quality

of the investigation.


The intention is to remedy the situation, not to discipline an individual.

What should be done if the investigation reveals"human error"?

- It will also allow future events to happen from similar causes

because they have not been reported.

R


176° 178°

38°

40°

42°

WELLINGTON

0200

0500

0745

0850

0200

0500

0745

0850

So recommendations…


This will run counter to the real purpose of the investigation,

and would jeopardize the chances for a free flow of information infuture accident investigations.

Never make recommendations about disciplining

a person or persons who may have been at fault.


- Conduct a job hazard analysis to identify and control hazards.

- Revise work methods to match crew capabilities and or limitations.

- Develop or modify work procedures to reduce risk.

- Change work space, equipment location or work flow.

- Improve environmental conditions.

Recommendations for corrective actions may include things like :



- Provide appropriate tools and equipment.

- Train crew and officers.

- Eliminate or control identified hazards.

- Increase inspection procedures.

- Identify personal protective equipment (PPE) required and ensure that it is used.


Recommendations for corrective actions may include things like :


Something to think aboutSomething to think about

- Language- Language People with university People with university degree may have a degree may have a

vocabulary ofvocabulary of20,000 to 30,000 words20,000 to 30,000 words..

Less educated peopleLess educated peoplehave only a vocabularyhave only a vocabulary

of of 6,000 words6,000 words..

We must choose a simple vocabulary if wewant to be understood.



Cu

ltu

ral b

arri

ers

Tomorrow Urgent

Tomorrow ?Not Urgent

- The problem with writing recommendations could be of acceptance.

- If the concerned parties do not agree, there may be a conflict.

Ships in Service A-M CHAUVEL


How to avoid a conflict

The investigator can avoid many of the acceptance problems by preparing the report carefully with the following considerations :

- Identifying who the recipients are and draft recommendations accordingly.

- Consider the possible opposition to the recommendations.

- Define conformance criteria i.e. don’t just criticize that fire extinguishers were not serviced. Give servicing interval criteria and address how it should be provided.



Process

7.0 Implement the plan



- Responsibility for the implementation and follow-up should be specifically assigned to individuals to carry out the actions within a set time period.

- The company needs to co-ordinate this action plan so that its policies and objectives are translated into practice.

Implement the Plan


It is vital to make sure that recommendations are implemented and followed-up.

“The Company should establish procedures for the implementation of corrective action”

Basically, the company should have procedures for carrying out the corrective actions suggested by analysis relevant to accident/incidents and near-misses identified from internal audits and during operations.

Implement the PlanExtract from the ISM Code - paragraph 9.2

Internal audits should ensure effectiveness of the procedures for implementing corrective actions.


“The Company should establish procedures for the implementation of corrective action”

Personnel on board and ashore should be aware of the procedures for investigating and follow-up of incidents or accidents.

Implement the PlanExtract from the ISM Code - paragraph 9.2

Evidence of records, corrective actions and timely implementation should be readily available.


Process

8.0 Evaluate theeffectiveness of

the corrective action



Identification of Identification of the eventthe event

SuggestionsSuggestionsfor improvementfor improvement

Implementation ofImplementation ofthe corrective actionsthe corrective actions

Recording of Recording of the action takenthe action taken

ReviewRevieweffectivenesseffectivenessof the actionof the action

InvestigationInvestigationof the causesof the causes

Corrective actionCorrective action


Effectiveness of the corrective action

- Ensure performance standards are achieved

through correct application of technology.

- Identify potential hazards for the particular

operation and assess their significance.

- Analyse the identified hazards to establish

their risk level and seek solutions for

their reduction to tolerable risks.

The SMS should ensure the following tasks are fulfilled for the implementation :



MaterialWork &

Task

People

ManagementSystem

Environment

Management Oversight and Risk Tree Ships in Service Training Material A-M CHAUVEL

Assure Performance Standards

See module

Are achieved

The SMS should ensure the following tasks are fulfilled for the implementation :


- Prepare for the possibility of any possible emergency linked to the operation. - Introduce suitable controlling mechanisms to prevent deviation from established safety limits.

- Carry out training and medical checks and update records.

- Provide controls in the procurement process for equipment and materials, and supervision of sub-contractors.

S.ISIK


Process

9.0 Make changesfor

continuous improvement



Title 1Seafarers requirement

Title 2Conditions of employments

Title 3Accommodations and catering

Title 4Health to Social protection

Title 5Compliance and enforcement

ILO - MLC 2006 Training Course


Preventive actionPreventive action

Identification of a Identification of a potential eventpotential event

Determination of Determination of the preventive the preventive

actionaction

Implementation of theImplementation of thepreventive actionpreventive action

Recording of theRecording of theaction takenaction taken

Review ofReview ofthe actionthe action

effectivenesseffectiveness

Determination ofDetermination ofthe root causesthe root causes


Continuous Improvement

A so perfect illusion


A so sorry reality


Never again

Nunca mais

Learn from these bad experiences

A-M CHAUVEL - BUREAU VERITAS - DNS / DCO

Cleveland (US) 1944


The year that a Liquid Natural Gas explosion incinerated a square mile of downtown Cleveland, Ohio.

The spill that created this blast was approximately 5% of the volume held by a modern LNG tanker.

The explosion destroyed 79 houses, two factories, and 217 cars.

Its heat reached 1000 degrees, killed 130 and injured 275.

A-M CHAUVEL - BUREAU VERITAS - DNS / DCO Ships in Service Training Material A-M CHAUVEL

300 tons of ammonium nitrate

blew up on September 21, 2001,at 10:30 in the morning.

It killed 30 people directly, seriously injured 3,000 more

damaged 25,000 houses

Estimated cost : 100,000 € millions.

AZF chemical plantToulouse (France) 2001


Ghislengien (Belgium) 2004

The number of miles debris was flung away from an LNG explosion at an industrial park 20 miles outside of Belgium.15 people were killed, 120 injured andmany severely burned.

A-M CHAUVEL - BUREAU VERITAS - DNS / DCO Ships in Service Training Material A-M CHAUVEL

$1 billion : The amount of damage from an explosion at a LNG facilityin Algeria that killed 27 people.

Skikda (Algeria) 2004

Date post:	15-Jan-2016
Category:	Documents
Upload:	lee-norris
View:	236 times
Download:	20 times

Ships in Service Training Material 2009 Past theory accident causation Contemporary theory...

Documents