LESSONS FROM ACCIDENTS

An effective system for learning lessons from accidents, incidents and near miss incidents would need to include the following elements, namely_ An incident/accident reporting system; _ A process for incident investigation that ensures that the underlying as well as immediate causes of accidents and incidents are understood, taking full account of human and organizational factors; _ A process for analyzing cumulative information on accidents and incidents from both internal and external events; _ A process for ensuring that the findings of incident investigation and analysis of accident and incident data are acted upon in a timely fashion and suitable interventions put in place or modifications made to prevent a recurrence of the incident or similar incidents; _ A process for evaluating the success or otherwise of interventions and modifications; _ A process for disseminating information on accident and incident causation and suitable interventions/modifications to all relevant parties (both internal and external), as quickly as possible; _ A system to capture the information in a format that is readily searchable and retrievable to allow ease of access, so that any lessons learned stay learned (corporate memory). In a well managed organization, the elements of an effective learning lessons process outlined above (with the exception of elements of dissemination of information) should form part of a good health and safety management system. That is, it should not generally be necessary to specifically have a separate learning lessons system. Accident investigation is like peeling an onion. Beneath one layer of causes and recommendations there are other, less superficial layers. The outer layers deal with the immediate technical causes while the inner layers are concerned with ways of avoiding the hazards and with the underlying causes, such as weaknesses in the management system. Very often only the outer layers are considered and thus we fail to use all the information for which we have paid the high price of an accident. It is not suggested that the immediate causes of an accident are any less important than the underlying causes. All must be considered if we wish to prevent further accidents, as the following examples will show. But putting the immediate causes right will

prevent only the last accident happening again; attending to the underlying causes may prevent many similar accidents.

Lesson from a Near Miss Incident:

A little girl was crossing a bridge over a river with her father. The father was afraid that his small daughter could fall in the river, he asked her to hold firmly his hand. She said: No Dad, you hold firmly my hand. The father immediately questioned her: what is the difference? She replied: there is a big difference Dad. If I hold your hand and for some reason I could not any more withstand keeping it, I would simply leave your hand and fall down in the river. However, if you hold my hand I am sure whatever happens you will not let me fall down in the river. Our relationship at work should be like this. Manager looking after his team, Supervisors taking care of their subordinates. We all need to be enjoying work together in a safe manner and avoid any harm to members of the workforce family. We have to learn from each incident to ensure the same oversight does not happen again. If we do not learn then any one of us could be the next victim. The incident investigations have revealed that the root causes are deficiencies in work planning, ineffective supervision and leadership, failure to implement procedures and improper behavior. Near misses are defined as incidents that under slightly different circumstances could have caused illness, injury or damage to assets, the environment or company reputation, but did not. All near misses shall be treated as incidents and shall be investigated and reported according to their potential risk. For example, an employee of a construction firm, while walking from one area of a project to another, observed a inch lock nut lying on the ground. Other than his casually noticing this nut, he paid no particular attention and continued on to his work point. After working a short while, he discovered that his mind was not concentrated on his work efforts, but his thoughts were being directed to the small nut lying on the ground. Having been indoctrinated in the safety movement, and curious as to where the nut came from, he decided to investigate. He located the nut and delivered it to his supervisor, explaining to him his theory that the nut was not, to his knowledge, a component of project materials being used. He suggested that perhaps it had loosened from a piece of operating equipment and that an unsafe condition may have been created. The supervisor was rather dubious as to the mans thinking but decided to investigate. Final investigation and inspection of equipment revealed that the nut had become detached from an important holding bolt of the blade frame structure of a bulldozer being operated nearby. The bolt was still partially in position but had commenced to dislodge from its intended operation. The superintendent of the project asserted that had the bolt not been detected, serious injury to the operator or other employees could have been the result.

This incident illustrates that importance of ever being on the alert for the little infractions of accident prevention a small lock nut, a split shovel handle, a protruding nail, a carelessly discarded piece of wood. Eliminate the little things and youre on your way to a safe operation. The Little Things That Count is akin to the phrased so often used to best describe fire prevention, Extinguish the Incipient Fire, and the Infernal Blaze is Denied Birth.

Lesson from a Minor Incident:

The term safety expert is used frequently by those not actively engaged in the field for accident prevention. You seldom hear it in conversation or discussion among participants in the safety movement. Men in the field of safety will refer to each other as safety engineers or more likely, safety men. The term expert implies the ability to move about unerringly pointing out exactly how specific hazards can be eliminated and laying down the ideal rule that will prevent accidents. One such Safety Expert allowed a contract worker for scraping the chemical deposits over the interior surface of a big reaction tank. Of course, being Safety expert he has religiously undertaken Job Briefing prior to allow the contract worker for the particular assignment. The Safety Expert expected that Portable Electrical Lighting with the supply voltage of only 24 Volts could have been given inside the reaction tank. But he failed to verify the fact. All of a sudden, the power went off and the contract worker immediately tried to get out of the tank as per the Job Briefing instructions of the Safety Expert. Unfortunately the contract worker hit against the Portable Lamp Holder and the bulb broken to cause him minor injuries over his head. He was given the First-Aid and then taken to the Medical Centre for further attention. We cant take things for granted! Though the Safety Expert insisted on the provision of 24 Volts supplied Portable Electrical Lamp inside the reaction tank, the electrician didnt care for the safety instruction. The probability of the contract worker hitting against the Portable Lamp Holder and the electrical power resumption coincided the hitting could have resulted in the electrocution of the contract worker. Here again, the Safe System of Work shall be established with the extension to the Safe System of Work i.e. Permit-ToWork procedures adhered without fail.

Lesson from a Serious Accident:

A welding contractor was killed while repairing a 1:25-inch by 0.5-inch crack on the bottom of a clarifier water tank at a Foods Facility. The 23-foot-tall tank was used to separate dirt and debris from wastewater in a potato-washing process area. The tank was open at the top and had a metal skirt around its cone-shaped base. While the welder was working inside the tank, an explosion occurred; the internal tank structures collapsed, resulting in his death.

It was determined that approximately 14 inches of debris-laden water leaked through the crack in the tank and entered in the hidden space under the tank skirting. Examination of a sample of the liquid indicated that bacterial decomposition of the organic matter likely produced flammable gas, which was then ignited by the welding activity. The bacteria likely produced hydrogen, a highly flammable gas, which ignited during the welding work.

In this case, Food Facility had safety personnel tested for combustible gases inside the tank prior to the hot work, but only from the entrance of the tank and no flammable gas was detected. Monitoring for combustible gases was not conducted in the immediate area of the crack just prior to the initiation of the welding or in the adjacent space where flammable gas was present. Were the resource persons inadequately Personnel Trained on the use of the specific combustible gas detector that was used and no hot work permit had been issued prior to commencing the welding. The following are the main lesson from the above serious accident: Hazard Analysis has not been conducted taking into consideration that there is risk of flammable gas production from anaerobic bacteria growth due to the decomposition of organic waste materials beneath the tank; Periodic or continuous monitoring of the atmosphere both inside and outside vicinity of the tank shall be monitored; and Written Permit-To-Work system shall be established and adhered.