Transcript
7/29/2019 1.1 Investigating Accidents
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NEBOSH, International Certificate in Oil & Gas
Operational SafetyModule 1.1 Investigating Accidents
Explain the purpose of and procedures for
investigating incidents and how the lessons learnt
can be used to improve health and safety in the oil
and gas industries
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Operational SafetyModule 1.1 Investigating Accidents
FLIXBOROUGH PIPER ALPHA
LONGFORD, AUS
HUMBER REFINERY
TEXAS CITY
BUNCEFIELD
ROUGH 47/3-B
1 JUNE 1974 6 JULY 1988
25 SEPT 1998
16 APRIL 2001
23 MARCH 2005
11 DECEMBER 2005
16 FEBRUARY 2006
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NEBOSH, International Certificate in Oil & Gas
Operational SafetyModule 1.1 Investigating Accidents
VIDEO CASE STUDIES
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NEBOSH, International Certificate in Oil & Gas
Operational SafetyModule 1.1 Investigating Accidents
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NEBOSH, International Certificate in Oil & Gas
Operational SafetyModule 1.1 Investigating Accidents
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Operational SafetyModule 1.1 Investigating Accidents
The process and purpose of
investigating occupational incidents
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Operational SafetyModule 1.1 Investigating Accidents
Reasons for investigation of accident / incident / near
miss
To identify immediate and root causes
To identify corrective action
To record the facts of the incident
For legal reasons
For claims management
For staff morale
For disciplinary purposes
For data gathering purposes
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NEBOSH, International Certificate in Oil & Gas
Operational SafetyModule 1.1 Investigating Accidents
Why must accidents and ill health be reported? As an employer, a person who is self-employed, or someone in control of work
premises, you have legal duties under Reporting of Injuries, Diseases andDangerous Occurrences Regulations 1995 (RIDDOR) that require you to reportand record some work-related accidents by the quickest means possible
The following must be reported:
Deaths
Major injuries
Over three-day injuries
Reportable diseases
Reportable dangerous occurrences (near misses)
Reportable gas incidents
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NEBOSH, International Certificate in Oil & Gas
Operational SafetyModule 1.1 Investigating Accidents
Why should we carry out accident investigations?
Identify patterns of occurrence of accidents and incidents - types of
machines, activity, part of the body injured
Identify trends - increasing or decreasing numbers of occurrence
Identify high risk activities that require further control
Obtain information for civil claims
Identify the immediate and underling cause of the accident!
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NEBOSH, International Certificate in Oil & Gas
Operational SafetyModule 1.1 Investigating Accidents
Immediate cause cause for accidentsPremises - Physical layout, condition of building, environment (weather),
tripping & slipping hazards
Plant and Substances - Machinery guarding, substance in use - toxic, harmful,
mobile plant, condition of work equipment - hand tools, chairs
Procedures - Written system of work or operating procedure to be followed,
safety policy, work instruction, quality standard, custom and practice
People - Human factors, state of health and fitness for work, abilities, fatigue,errors knowledge based. skill based (slip or lapse), rule based, violations,
behaviour pressures, culture
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Operational SafetyModule 1.1 Investigating Accidents
Underlying (root) cause for accidents
Planning Ineffective planning of tasks, ineffective planned maintenance
Risk assessment absent or not suitable and sufficient
Control - Poor supervision, unclear roles and responsibilities
Co-operation - Between staff and management or contractors
Communication - Verbal, written, information, posters
Competence - Instruction, training, experience
MonitoringAdequacy of pro-active and reactive
Reviewing Overall review and response to change
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Operational SafetyModule 1.1 Investigating Accidents
Basic Accident Investigation Procedures
Decide on a team, include safety representatives, managers,
specialists
Attending the Scene:
Ensure area is safe and try not to tamper with information / evidence
Take photographs / video
Measurements and sketches: record vital information
View and collect relevant documents
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Operational SafetyModule 1.1 Investigating Accidents
WitnessesInterviewing Witnesses:
I kept six honest serving men,They taught me all I knew,
Their names are What and Why and When
And How and Where and Who?Rudyard Kipling
Primary those involved
Secondary eye witnesses Tertiary those that did not witness the event but can provide information on methods work and management arrangements
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Operational SafetyModule 1.1 Investigating Accidents
Interviewing Witnesses
Should invite a safety representative to be present
Be neutral not a counselling session or an interrogation
Ask open questions about the incident
Record a summary / statement for each person interviewed and
seek agreement
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Operational SafetyModule 1.1 Investigating Accidents
Barriers for reporting accidents / incidents and near
misses
Blame culture
Human error
Perception
Attitude
Unmotivated
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Operational SafetyModule 1.1 Investigating Accidents
The organisational requirements for recording
and reporting occupational incidents
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NEBOSH, International Certificate in Oil & Gas
Operational SafetyModule 1.1 Investigating Accidents
Why must accidents and ill health be reported?
As an employer, a person who is self-employed, or someone in control of workpremises, you have legal duties under Reporting of Injuries, Diseases andDangerous Occurrences Regulations 1995 (RIDDOR) that require you to reportand record some work-related accidents by the quickest means possible
The following must be reported:
Deaths
Major injuries
Over three-day injuries Reportable diseases
Reportable dangerous occurrences (near misses)
Reportable gas incidents
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