accdt investigation & lesson learnt.ppt

8/16/2019 ACCDT INVESTIGATION & LESSON LEARNT.ppt

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ACCIDENT

INVESTIGATION,

&LESSON’S

LEARNT


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OBJECTIVE

To day we shall

• Discuss what is an Accident

• Study Accident reporting system &procedure of our Corporation

• Learn ‘How to investigate an accident

• Lessons learnt from accidents and• How to prevent recurrence


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Accident is an

unplanned event that interrupts the

completion of anactivity & that may

or may not resultsin to injury or

property damage.


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As per Factories Act , an accident is

• any incident which causes death

•Serious in!ury li"ely to prove fatal# unconsciousness

•Loss of $ody part%s•'odily in!ury which prevents the in!ured to a$sent from duty

more than () hrs*

• Serious $urns

• collapse of wall+floor+roof or $uilding forming part of the factory

Accident


5/52

As per Petroleu act ,

an accident is any fire or e,plosion # as a result of ignition ofpetroleum or petroleum -apour attended with loss of human

life or Serious in!ury or loss of property*

As per .lectricit! act ,an accident is any in!ury or loss of life to human $eing or

animal due to electrical supply

As per /otor "e#icle act

an accident is any in!ury or death to any person or

damage to any property as a result of motor vehicle

0nvolvement

Accident


6/52

As $er %ater Act ,

an! $ollutin atter in e'cess o( t#e $rescri)ed

liit is )ein disc#ared or li*el! to )e

disc#ared in to a strea or +ell

As $er Air Act ,

%#ere t#e eission o( an! $ollutant in to t#eatos$#ere in e'cess o( t#e standards laid do+n

)! t#e state PC- occurs or is a$$re#ended to

occur due to soe un(oreseen act or e"ent

As $er En"ironent Act ,

+#ere t#e disc#are o( en" $ollutant in e'cess o(

t#e $rescri)ed Stds occurs or is a$$re#ended to

occur due to an! un(oreseen act or e"ent

Accident


7/52

Accidents to $e reported as per 10SD

2* All fire incidents which has lasted for more than 23 minutes or resulted in shutdown of the unit

4* Any incident involving fatality # in our 5remises or the

death of our employee any where on duty*

6* Any incident involving in!uries of our employees

resulting in a$senteeism from duty for () hours or

more

(* 0ncident involving property loss of more than 3 lacs

3* 'low out or e,plosion

7* Loss of 388 man9hour or more*:* 5ermanent loss of $ody parts

)* Lea"age of Hydrocar$on or ;as from tan"+5ipelines

resulting in stoppage of operation*


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0* To $e reported $y Location in charge immediately

• To the concerned Departmental H1D of State*• eporting of reporta$le accidents

% L5; + 51L Locations


9/52

0* To $e reported $y Location in charge+Admn* 0n9charge immediately

• to the Departmental Head of the >egion• ;/ %>egional Service #• 0n9 charge of S & .5 of the >egion

00* egion + H1• Concerned .D + ;/ 0n9charge + 5rincipal panelist at H1• Dir %/ in case of accidents involving ma!or in!uries # death# fire*• D;/ % C + S# H & . dept C1 # 5.S1 Dept =agpur

• eporting of >eporta$le accidents

%Aegional Admn*'uilding


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i To $e reported $y Location in charge to the concerned Departmental

Head + Head of the State

i egional Services

$ 0n charge of S&.5 of the >egion & H1

c Concerned .D + ;/ in charge + 5rincipal panelist at H1

d .D %S#H & .+C1# =ew Delhi

iii 'y 5rincipal 5anelists# H1 on ?uarterly $asis to @ .D# 10SD# =ewDelhi

>eporting of =on >eporta$le%including near9miss

accident


11/52

i To $e reported $y Location in charge to

a Head of the Department at the >egion

$ 0n charge of S&.5 of the >egion

c ;/# >egional Services

ii egion after investigation of incident to

a 0n charge of S&.5 of the >egion & H1

$ Concerned .D + ;/ in charge + 5rincipal panelist at H1

c .D %S#H & .+C1# =ew Delhi

iii 'y 5rincipal 5anelists# H1 on ?uarterly $asis to @ .D# 10SD# =ewDelhi

>eporting of =on >eporta$le %including near9 miss

accident


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eport of Accident

2* =ame of the Location @

4* Site of Accident @

6* Date and Time of Accident @

(* 'rief of .vents including status at

the time of reporting actions ta"en#

potential haBards %if any @

3* 5ro$a$le reason%s of Accidents @

7* =o* of casualty %if any9own employees @ 9 others

:* =o*of in!ured persons9 1wn employees

9 others

)* .,tent of damage to 5lant+/achinery+

structures + $uildings+pu$lic property @* 0mpact on operations @

28* Assistance %if re?uired @

Signature @

Designation@

Date+Time


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>eporting of .lectrical Accident

All electrical accidents

to $e reportedas per section (( a

of

0ndian .lectricity

rules 237


15/52

EINRIC AXIOMS OF IND. SAFETY

2* TH. 1CC>>.=C. 1< A= 0=E>F 0=-A>0A'LF >.SLTS1/ A C1/5L.T.D S.G.=C. 1< S*

4* TH. =SAS1=S A>. >.S51=S0'L. A

/AE1>0TF 1< ACC0D.=TS*

6* TH. 5.>S1= H1 S>1 .SCA5.S*

(* TH. 1CC>>.=C. 1< TH. ACC0D.=T THAT >.SLT 0=0=E>F 0S LA>;.LF 5>.-.=TA'L.*

3* TH. ( 'AS0C /1T0-.S 1CC>>.=C. 1< =SA1-0D. A ;0D. T1 TH. S.L.CT01= 1< A55>15>0AT. C1>>.CT0-. /.AS>.S*


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7* 'AS0C /.TH1DS 5>.-.=T0=; ACC0D.=TS A>. – .=;0=..>0=; >.-0S01= # 5.>SAS01= & A55.AL # 5.>S1==.L ADEST/.=T & D0SC05L0=.*

:* /.TH1DS 1< /1ST -AL. 0= ACCDT 5>.-.=T01=* A>. A=AL1;1S 0TH TH. /.TH1DS >.GD* TH. C1=T>1L 1< GAL0TF # C1ST & GAL0TF 1<5>1DCT01=*

)* /;T* HAS TH. '.ST 1551>T=0TF & A'0L0TF T1

0=0T0AT. TH. 1>I 1< 5>.-.=T01=*

* S5.>-0S1> 0S TH. I.F /A= 0= 0=DST>0AL ACCDT*5>.-*


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28* TH. H/A=0TA>0A= 0=C.=T0-. 5>.-.=T0=;

ACC0D.=TAL 0=E>F 0S S55L./.=T.D 'F T151.>.CT C1ST 1< 0=DST>0AL 0=E>0.S

C1/5.=SAT01= CLA0/S & TH. /.D0CAL

T>.AT/.=T 0S 'T ONE – FIFT0 1< TH. T1TAL C1ST

H0CH TH. ./5L1F.> /ST 5AF *


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ACCIDENT RATIO ANAL/SIS

No In1ur! Accidents

2

34

566

7a1or or Lost Tie In1ur!

7inor In1uries

0einric# 82496:

0% 0EINRIC0 8GER7AN/: ; 2452 8Started t#e Researc#: 2 Accidents

FRAN? E -IRD 8.SA: ; 24@4 8Pro$osed t#e Ratio:

ACCIDENTS %IT0 NO VISI-LE

IN.R/ OR DA7AGE

PROPERT/ DA7AGE

ACCIDENTS

7INOR IN.RIES

SERIO.S OR DISA-LING 1

10

30

600

-ird 824@4:

Pro$ert! Daae Accidents

Near 7isses 8Non In1ur!B Daae Accidents:

2

>6

=66

96

5

Fatal or serious in1ur!

First Aid Treatent In1uries7inor In1uries

T!eBPearson 824


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E0EMENTS 1 IC

CO20D RES20T INTO

INCIDENTS

3. PEOP0E

4. E52IPMENT

6. MATERIA0

7.

EN8IRONMEN

T


21/52

A large storage tan" containing

flamma$le li?uid overflowed in evening

time when it was $eing filled* The levelindicator and level alarm system of the

tan" was defective and the operations

was not monitored* 0nitially the overflowwas not detected* A security guard

noticed a strong odor and immediately

called the area operations personnel*

Two operators responded $y driving a

truc" to the area to investigate*


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Within minutes, there was a loud

explosion and fre. (It is believed

that their truck provided the ignitionsource) It took plant and civic

personnel a day and a hal to

extinguish the fres which moved

rom one tank to the next. ore

than a do!en employees werehospitali!ed and there was

signifcant property damage.


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Wh t * + '


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• Transfer of product is always a ris" withpotentially significant conse?uences*

/onitor transfers closely so you can detectand respond to spills and lea"s earlyKKKK

• =ever drive into a flamma$le cloudK -ehiclescan provide ignition sources — such as a hotengine manifold or muffler* These are oftenwell a$ove the auto9ignition temperature ofmany flamma$les* >emem$er# if a cloud isignited $y the vehicle you are driving# you

will have a front row seat and $e the centerof the e,plosion*

• Ta"e every report of an unusual occurrenceor odor seriously and respond ?uic"ly and

thorou hl *

What *ou +an 'o


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HF T1 CA>>F 1T ACC0D.=T 0=-.ST0;AT01=

• To find out the cause of accidents &prevent recurrence

• To fulfil any legal re?uirements

• To determine the cost of an accident• To determine compliance with

applica$le safety regulations• To process wor"ers claims


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A!!"D#NT "N(#ST"%AT"ONSD#T#$,"N# HO & H)TH#S# A"'U$#S O!!U$.

1) US"N% TH# "NO$,AT"ON%A"N#D TH$OU%H AN"N(#ST"%AT"ON3 A S","'A$ or

/#$HA/S ,O$# D"SAST$OUSA!!"D#NT !OU'D 1# /$#(#NT#D.


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35/52

Accidents are usuallycomple4. "t may have 56 or

more event that can 7e thecauses.

A detail analysis normallyreveal 8 cause levels-

1asic

"ndirect

Direct


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"n spite of their

comple4ity3 mostaccidents are

preventa7le 7yeliminating one or

more causes.

OBJECTIVES OF INVESTIGATION


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OBJECTIVES OF INVESTIGATION

1. Reduce daner to e$lo!ees and

susce$ti)le $u)lic

3 Pre"ent co$an! resource losses

5 Pre"ent (urt#er is#a$s

= Res$ond to anaeent needs

9 Pre"ent loss o( trained $ersonnel


38/52

O-ECTIVES OF INVESTIGATION

@ De"elo$ in(oration


39/52

"nvestigative /rocedures

Actual Procedures used in a

particular investiationdepend on t!e nature and

results o" t!e accident#


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5. Scope of "nvestigation

9. Selection of investigators. Assignementof specific tas: to each

8. %et /reliminary 7riefing on

Description of accident Normal Operating /rocedure

,aps

'ocation of Accident Site

'ist of ;itnesses #vents that preceded the Accident

"nvestigative /rocedures


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Accident In"estiation


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H1 @ ho was involved in the accident

ho noticed the accident

ho reported the accident ho was responsi$le for Safety

ho was responsi$le for the accident

ho was called to respond to the accident

HF@ hy did the accident happen M

hy safety practices were not applied M

hy did safety procedures failed to wor" M

HAT @ hat actually happened M hat were the losses incurred

hat in!uries were sustained M

hat could have $een done to avoid the

occurrence M



45/52


H.>. @ here did the accident occur

here was the safety officer or Shift in9charge

at the time of accident M

H.= @ hen did the accident occur M

hen were people aware that an accidentoccurred

hen did help arrive at the sight of accidents M

H1 @ How did the event occur M %e*g rapidly# slowly#

without warning etc*

How could safety procedures and practices have

$een improved M

How does the organiBation learn from the

accidents occurrence $


46/52

ecord pre accident conditions # the accident se?uence

and post accident conditions

• 0nterview the witness as soon as possi$le after anaccident

• Document the location of victims# witness# machinery#

energy sources and haBardous materials*

0nterviews


47/52

0nterviews

• ;et preliminary statement as soon as possi$le from all

witness• Locate the position of each witness on a master chart

%including the direction of view• Let each witness spea" freely and ta"e notes without

distracting the witness• >ecord the e,act words used $y the witness to descri$e

each o$servation• 0dentify the ?ualification of each witness %name# address#

occupation Fears of e,perience# etc*•Supply each witness with a copy of the statements*

>eport of investigation


48/52

>eport of investigation2* 'ac"ground information

a here and when the accident occur

$ who and what were involved

c 1perating personnel and other witness

4* Account of accident %what happened

a Se?uence of events

$ .,tent of damage

c Accident type d Source of energy & haBardous material

6* Discussions %analysis of accidents how & why

a Direct causes %energy sources# haBardous material

$ 0ndirect causes %unsafe acts and conditions c 'asic causes % /anagement policies# personal or

environmental factors*

(* >ecommendations to prevent a recurrence %immediate &

long range


49/52

An investigation is notcomplete until all data areanalysed and a final report iscompleted.

"n practice3 the investigative;or:3 data analysis and

report preparation proceedsimultaneously.


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SAFETY MANA9EMENT

PRINCIP0E 3 :

, A= =SA1=; 0= TH. /;T* SFST./*N

PRINCIP0E 4 :

, . CA= 5>.D0CT THAT C.>TA0= S.TS 1<

C0>C/STA=C.S 0LL 5>1DC. S.-.>.0=E>0.S* TH.S. C0>C/STA=C.S CA= '.0D.=T01LL.D*


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PRINCIPLE 5

SA;A=0S0=; # C11>D0=AT0=; # D0>.CT0=; &

C1=T>1LL0=; T1 ACH0.-. TH./ * N

PRINCIPLE =

TH. I.F T1 ..S THAT


52/52

PRINCIP0E ; :

,

TH. 1>S THAT ALL1

ACC0D.=T T1 1CC> * TH0S CA= '. CA>>0.D

1T 0= T1 AFS@

-/ SEARC0ING FOR ROOT CA.SES OF ACCIDENTS &

-/ SEARC0ING FOR CERTAIN ?NO%N EFFECTIVE

CONTROLS

accdt investigation & lesson learnt.ppt

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