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1、Accident InvestigationsAlthough accide nt in vestigati on 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 recog nize un til they result in an accide nt or in cide nt. In complicated accidents it may
2、take an investigation to actually determine what the cause of the accide nt 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 faultfinding process with the purpose of affixing blame. The end of any r
3、esult of an accide nt in vestigatio n should be to assure that the type of hazard or accide nt does not exist or occur in the future.Your compa ny should have a formalized accide nt inv estigati on procedure, which is followed by every one. It should be spelled out in writi ng and end with a writte
4、n report using as a foundation of your standard company accident investigation form. It may be your workers compe nsati on form or an equivale nt from your in sura nee carrier.Accidents and even near misses should be investigated by your company if you are intent on ide ntify ing and preve nting haz
5、ards in your workplace. Thousa nds of accidents occur throughout the United States every day. The failure of people, equipme nt, 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 in
6、formati on gained through an inv estigati on, a similar or perhaps more disastrous accide nt may be preve nted. Accide nt inv estigati ons should be con ducted with accide nt preve nti on in mind. In vestigati ons are not to place blame.An accide nt is any un pla nned eve nt that results in pers ona
7、l injury or in property damage. When the pers onal injury requires little or no treatment it is mi nor. If it results in a fatality or in a perma nent total, perma nent partial, or temporary total (lost time) disability, it is serious. Similarly, property damage may be minor or serious. Investigate
8、all accident regardless of the extent of injury or damage. Accidents are part of a broad group of eve nts that adversely affect the completi on of a task. These eve nts are in cide nts. For simplicity, the procedures discussed in later sect ions refer only to accide nts. They are, however, also appl
9、icable to in cide nts.1. Accide nt Preve ntio nAccide nts are usually complex. An accide nt may have 10 or more eve nts that can be causes. A detailed an alysis of an accide nt will no rmally reveal three cause levels: basic, in direct, and direct. At the lowest level, an accide nt results only whe
10、n a pers on or object receives an amount of en ergy or hazardous material that cannot be absorbed safely. This energy or hazardous material is the DIRECT CAUSE of the accide nt. The direct cause is usually the result of one or more un safe acts or un safe con diti ons, or both. Un safe acts and con
11、diti ons are the in direct causes or symptoms. In turn, in direct causes are usually traceable to poor man ageme nt policies and decisions, or to personal or environmental factors. These are the basic cause.In spite of their complexity, most accide nts are preve ntable by elim in at ing one or more
12、causes. Accide nt inv estigati ons determ ine not only what happe ned, but also how and why. The in formatio n gained from these in vestigati ons can preve nt recurre nee of similar or perhaps more disastrous accide nt. Accide nt inv estigati ons are in terested in each eve nt as well as in the sequ
13、e nee of eve nts that led to an accide nt. The accide nt type is also importa nt to the inv estigator. The recurre nee of accide nt of a particular type or those with com mon causes shows areas n eedi ng special accide nt preve nti on emphasis.2. In vestigative ProceduresThe actual procedures used i
14、n a particular investigation depend on the nature and results of the accident. The agency having jurisdiction over the lacation determines the adm ini strative procedures. In gen eral, resp on sible officials will appo int an in dividual to be in charge of the inv estigati on. An accide nt inv estig
15、ati on should use most of the followi ng steps:Defined the scope of the investigation.Select the inv estigati on. Assig n specific tasks to each (preferably in writi ng).Present a preliminary briefing to the investigating team.Visit and in spect the accide nt site to get updated in formati on.In ter
16、view each victim and wit ness. Also in terview those who were prese nt before the accide nt and those who arrived at the site shortly after the accide nt. Keep accurate records of each in terview. Use a tape recorder if desired and if approved.Determ ine the follow ing:What was not no rmal before th
17、e accide nt.Where the abno rmality occurred.When it was first no ted.How it occurred.Determ ine the follow ing:Why the accide nt occurred.A likely seque nee of eve nts and probable causes ( direct, in direct, basic ). Alter native seque nces.Determi ne the most likely seque nee of eve nts and the mo
18、st probable causes.Con duct a post-i nv estigati on briefi ng.Prepare a summary report including the recommended actions to prevent a recurre nee. Distribute the report accord ing to applicable in structi ons.An investigation is not complete until all data are analyzed and a final report is complete
19、d. In practice, the investigation work, data analyzed and report preparations proceed simultaneously over much of the time spent on the investigation.3. Fact-Fi ndingInvestigator collects evidence from many sources during an investigation, gets in formatio n from wit nesses and observati on as well
20、as by reports, in terviews witnesses as soon as possible after an accident, inspects the accident site before any cha nges occur, takes photographs and makes sketches of the accide nt sce ne, records all pert inent data on maps, and gets copies of all reports. Docume nts containing no rmal operat in
21、g procedures flow diagrams, maintenance charts or reports of difficulties or abno rmalities are particularly useful. Keep complete and accurate no tes in a bound no tebook. Record pre-accide nt con diti ons, the accide nt seque nce and post- accide nt con diti ons. In additi on, docume nt the locati
22、 on of victims, wit nesses, mach in ery, en ergy source, and hazardous materials.In some investigation, a particular physical or chemical law, principle, or property may expla in a seque nce of eve nts. In clude laws in the no tes take n duri ng the investigation or in the later analysis of data. In
23、 addition, gather data during the investigation that may lend itself to analysis by these laws, principles, or properties. An appe ndix in the final report can in clude an exte nded discussi on.4. In terviewIn gen eral, experie need pers onnel should con duct in terviews. If possible, the team assig
24、 ned to this task should in clude an in dividual with a legal backgro und. After in terviewi ng all wit nesses, the team should an alyze each wit ness statemermay wish to re-i nterview one or more wit nesses to confirm or clarify key poi nts.While there may be incon siste ncies in wit nessesstateme
25、nt, inv estigators shoiassemble the available testimony into a logical order. Analyze this information along with data from the accident site.Not all people react in the same manner to a particular stimulus. For example, a wit ness with in close proximity to the accide nt may have an en tirely diffe
26、re nt story from one who saw it at a distanee. Some witnesses may also change their stories after they have discussed it with others. The reason for the change may be additional clues.A witness who has had a traumatic experienee may not be able to recall the details of the accident. A witness who ha
27、s a vested interest in the result of the in vestigati on may offer biased testim ony. Fin ally, eyesight, heari ng, reacti on time, and the gen eral con diti on of each wit ness may affect his or her powers of observati on. A wit ness may omit en tire seque nces because of a failure to observe them
28、or because their importa nee was not realized.5. Report of Inv estigati onAs no ted earlier, an accide nt in vestigatio n is not complete un til a report is prepared and submitted to proper authorities. Special report forms are available in many cases. Others in sta nces may require a more exte nded
29、 report. Such repots are often very elaborate and may include a cover page, title page, abstract, table of conten ts, comme ntary or n arrative discussi on of probable causes, and a sect ion on con clusi ons and recomme ndatio ns.Accident investigation should be an integral part of your written safe
30、ty and health program. It should be a formal procedure. A successful accide nt inv estigati on determ ines not only what happe ned, but also finds how and why the accide nt occurred. Inv estigatio ns are an effort to preve nt a similar or perhaps more disastrous seque nee of eve nts. You can the n u
31、se the result ing in formati on and recomme ndati ons to preve nt future accide nts.Keep ing records is also very importa nt to recog nizing and reduci ng hazards. A review of accide nt and injury records over a period of time can help pinpoint the cause of view of accide nts. If a certa in worker s
32、hows up several times on the record as being inju red, it may in dicate that the pers on is physically un suited for the job, is not properly trained, or needs better supervision. If one or two occupations experience a high perce ntage of the accide nt in a workplace, they should be carefully an aly
33、zed and coun termeasures should be take n to elimi nate the cause. If there are multiple accide nt involving one machi ne or process, it is possible that work procedures must be cha nged or that maintenance is n eeded. Records that show many accide nts duri ng a short period of time would suggest an
34、 en vir onmen tal 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. An alysis of hazards forces us to take a serious look at them.事故調(diào)查盡管事故調(diào)查是一種事后危害識別的方法,它依
35、舊是危害識別的一個重要 組成部分。有時系統(tǒng)中存在人們無法識別的危害,直到事故或事件發(fā)生才能得 以辨識。對于復(fù)雜的事故,也許經(jīng)過事故調(diào)查才能真正發(fā)現(xiàn)事故原因,這種情 況尤其適用于發(fā)生人員死亡或缺少目擊者的事故。事故調(diào)查是一個不斷發(fā)現(xiàn)事 實的過程而不是以追責為目的的發(fā)現(xiàn)錯誤的過程。一項事故調(diào)查的最終結(jié)果應(yīng) 當確定危害或事故不存在或以后不會發(fā)生。一個公司應(yīng)該有一個編制好的事故調(diào)查程序,所有員工都應(yīng)當去遵守它。 這個程序應(yīng)該以書面方式講清楚具體過程并最終以標準的公司事故報告格式為 基礎(chǔ)編寫書面報告。它可能是以員工補償形式或者保險公司的方式。如果打算識別并且防止工作場所的危害,公司就應(yīng)當調(diào)查事故甚至是未
36、遂 事故。每天美國都會發(fā)生萬千起事故,人員失誤、裝置失效、供給不足或環(huán)境 缺陷往往是導(dǎo)致大多數(shù)事故發(fā)生的原因。事故調(diào)查可以確定這些失效如何與為 什么發(fā)生。通過使用調(diào)查獲得的信息,一種類似的事故或者也許其他種類災(zāi)難 性事故也可以得到有效避免。人們應(yīng)當牢記事故調(diào)查要以事故預(yù)防為目的來進 行,而不是追究責任。事故是任何導(dǎo)致人員傷亡或財產(chǎn)損失的計劃外的事件。如果人員傷害幾乎不 需要治療,那這種事故就比較低級。如果導(dǎo)致了人員死亡或者整體永久性、部 分永久性或整天暫時性失效,那這種事故就屬于嚴重級別。類似的,財產(chǎn)損失 也可以被分為輕微與嚴重。事故調(diào)查應(yīng)該無視事故傷害或損傷程度,對所有事 故進行調(diào)查。事故是
37、眾多阻礙了任務(wù)完成的事件的一部分。這些事件又被稱為 意外。為了實現(xiàn)簡化調(diào)查程序,以下部分討論的程序只涉及到事故,然而它們 也適用于意外事件。1. 事故預(yù)防事故往往比較復(fù)雜。一起事故可能由十件或更多事件導(dǎo)致。一份詳細的事故 分析一般將顯示為三種層次的原因:基礎(chǔ)的,間接的和直接的。在最低級原因 中,事故只是因為人或物受到了無法承受的一定量的能量或接觸了無法吸收的 危害物質(zhì)。這些能量或危害物質(zhì)就是事故的直接原因。直接原因經(jīng)常是一種或 多種不安全行為、不安全環(huán)境或者二者共同導(dǎo)致的。不安全行為或環(huán)境是間接 原因或征兆。反過來,間接原因經(jīng)??梢宰匪莸讲顒诺墓芾碚吲c決定或者人 為與環(huán)境因素。這是屬于基本原
38、因。盡管事故具有復(fù)雜性,通過消除一個或更多起因,大多數(shù)事故還是可以預(yù)防 的。事故調(diào)查不僅可以確定會發(fā)生什么,還可以確定事故是如何發(fā)生的,為什 么發(fā)生。這些調(diào)查獲得的信息可以幫助防止類似事故再次發(fā)生或者可能避免更 多的災(zāi)難性事故。事故調(diào)查不僅關(guān)注每一個事件,而且關(guān)注一系列可能導(dǎo)致事 故發(fā)生的事件。事故類型對于調(diào)查人員也很重要。一種特殊類型事故的再次發(fā) 生或者那些擁有共同致因的事故顯示了需要特殊事故預(yù)防重點的方面。2. 調(diào)查程序在一種特定的調(diào)查中實際使用的程序取決于事故的性質(zhì)與結(jié)果。在確定管理 程序方面,專門機構(gòu)的權(quán)限高于本公司。一般來說,責任機構(gòu)將會指定一人負 責調(diào)查。事故調(diào)查應(yīng)當要以下步驟的大
39、部分:1確定調(diào)查范圍2. 選擇調(diào)查對象,確定所需達到的目標(最好書面記錄)3. 向調(diào)查小組預(yù)先進行簡潔匯報4. 參觀并檢查事故場地,及時更新事故信息5. 訪問每一位受害者與目擊者,同時還要訪問那些事故發(fā)生前在場的人員 與事故發(fā)生不久后到場的人員。對每一個訪問進行準確的記錄,如果需要或允 許的情況下可以使用錄像帶。確定以下信息:1.事故發(fā)生前有何異常2異常發(fā)生在什么地方3. 什么時候首次被發(fā)現(xiàn)4. 如何發(fā)生5. 為什么事故會發(fā)生6. 可能導(dǎo)致事故發(fā)生的一系列原因(直接的,間接的,基礎(chǔ)的原因)7. 可替代的一系列原因8. 確定導(dǎo)致事故發(fā)生的最可能的原因9. 進行調(diào)查后簡短的匯報10. 準備總結(jié)報告,內(nèi)容應(yīng)當包括防止事故再發(fā)生的建議措施。根據(jù)建議的 適用性分發(fā)報告直到所有數(shù)據(jù)被分析并完成最終報告后,事故調(diào)查才能算完成。實踐過程 中,調(diào)查工作,數(shù)據(jù)分析和報告準備同時進行,事故調(diào)查的大部分時間都用于 這些步驟。3. 事實
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