ACCIDENTS/INCIDENTS need to be investigated thoroughly; primarily to ensure they do not happen again.
Enforcement agencies usually have the duel role of attempting to prevent the accident occurring again, and prosecuting breaches of the relevant occupational health and safety act.
The "Investigator's Rhyme" is useful and very applicable here:
"How and Why and Where and When?
Who and What? And back again..."
Repeat it two more time!
If you can answer each of these simple questions, you are going to be very close to the reasons the safety system broke down.
Two other interesting reminders for the 'searchers-of-facts' are:‘When the impossible has been eliminated, whatever remains, however improbable, must be the truth…’Sir Arthur Conan Doyle - ‘The Adventures of Sherlock Holmes’Vincenzio Galilei, father to Galileo Galilei, wrote in his book on music (‘Dialogue of Ancient and Modern Music’):
"… that they who in proof of any assertion rely simply on the weight of authority, without adducing any argument in support of it, act very absurdly. I, on the contrary, wish to be allowed freely to question and freely to answer you without any sort of adulation, as well becomes those who are in search of truth."
As quoted by Dava Sobel in her book "Galileo’s Daughter" Fourth Estate, London, 1999, pp17-18.
The questions posed on each side of the triangle above are also very succinct, ensuring a very good overview of the accident scenario if you can answer the relevant questions.
PEOPLE: What people are involved in the incident? In its broadest sense, this might include design and installation personnel of many years before the incident occurred. Other 'PEOPLE' related items to consider are:
- Physiological influences (eg pre-existing injury/incapacity/health/fitness/height/weight)
- Psychological influences (eg stress; drugs; demeanour; personality issues)
- Part in the hierarchy
- Elements of 'group think' (where everyone 'thinks the same' due to peer pressures/shyness etc.)
- Gender issues
- Ethnicity (Racism; Religion; Culture; Colour; Language)
- Training
PARTS: What plant and/or substances were involved and what were its dispositions? Again, broad considerations must be taken, such as when the last maintenance check was made, along with the corollary of what sort of maintenance check and how skilled was the maintenance person. Other perspectives to consider, include:
- Locked/unlocked plant and accessways
- Were switches in ON or OFF position, and what position should they have been in at the time of the incident?
- What sort of environmental issues existed, and what sort should have existed?
- Guards existing and in place?
- Weight
- Waste
- Surfaces
- Personal protective equipment (PPE)
- Clothing
- Any vehicles in the incident?
- What substances were in use and what information was available? What information
should have been available?
POSITION: Where was everything in relation to other things? Did an early morning start mean a cool starting environment in which some seals might leak under pressure (due to flexibility not being achieved until a higher ambient temperature has been reached)? Other 'positional' considerations would include:
- 4 dimensions - length; width; breadth; time
- Distance
- Pressure
- Volume
- Confinement
- Motion
- Direction
POWER: What sorts of energy were involved? Where isolation points known? Were isolation procedures available? Were they applied? COULD they be applied? And so forth... 'Power' considerations could include:
- Kinetic
- Potential
- Static
- Electricity
- Gas
- Flammable solids, liquids, vapours
- Decay
- Heat
- Cold
- Air-Pressure
- Hydraulics
- Gravity
- Centifugal
- Wind
- Water-pressure
And when all else fails? Call in an expert! Contact us and we can arrange an investigations expert to visit...