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#1 Posted : 28 January 2002 16:50:00(UTC)
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Posted By Martin Can anyone help with a source of clearly written, concise guidance on how to investigate for the root causes of accidents, ie how to look beyond the primary or short term causes to see what underlies problems, to give a more useful type of answer on the recommendations section of a report form (other than "should be more careful"!) Lots of web searching has been surprisingly fruitless so far. Any help gratefully recieved
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#2 Posted : 28 January 2002 18:42:00(UTC)
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#3 Posted : 29 January 2002 13:47:00(UTC)
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Posted By Rob Waldie Try appendix 5 of HSG65 - Successful Health & Safety Management.
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#4 Posted : 29 January 2002 14:20:00(UTC)
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Posted By Ken Taylor Here is a simplistic list of headings that I use as an aide-memoire: What? Where? When? To Whom? Is it safe? Has work stopped? Is area secured? Who has been informed? Who was in control of the site? Accident reports completed? Policy, Risk assessments, Safe working methods, Team, Individual, Task, Training, Supervision, Environment, Equipment, Photograph, Diagrams, Notes, Reports, Recommendations. Hopefully someone will point out my omissions so that I can improve this even further. It may not seem very 'professional' but when the 'baloon goes up' this is a lot more use than reams of paper and chapters from text books!
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#5 Posted : 31 January 2002 13:30:00(UTC)
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Posted By John Usher Martin, Why not get your company to send you on a course in Accident/Incident Investigation. There are loads of them about,some more expensive than others. It would show the company's commitment to safety. Regards John
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#6 Posted : 06 February 2002 20:59:00(UTC)
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Posted By Ann Pearson Often to find the 'root cause', a detailed analysis of where in the sequence of events is needed to identify the specific type of error that has taken place. A useful technique for doing this has been computerised in Investig8or at www.emsystems.co.uk. (the same technique can be carried out with pen and paper) There is also a list of links to some articles on accident investigation that may be useful to you.
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#7 Posted : 07 February 2002 12:43:00(UTC)
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Posted By Ciaran McAleenan Martin My advice: "Keep it simple". I have posted below section "c" of the Operational Analysis & Control (OAC) Model, recently show cased at ISSA International Construction Safety Conference in Paris. It deals with your topic. "C. Review the Effectiveness of the Operation 1. Has the operation progressed as planned? Things change or things can go wrong. You need to be aware of the effects of any change and try to anticipate how they will need to be dealt with. Ask yourself the following questions; · What has changed since the last operational analysis?’, ‘What effect will it have on operational management?’, and ‘How will it be dealt with?’, If nothing has changed then note that the review has taken place and set the next review date. Where things have gone wrong ask the following; · ‘What went wrong?’, ‘How did it happen?’, and ‘How did you deal with it?’. Note: We do not always get it right but if an accident does occur that is no reason to give up or to accept lower standards. Accepting accidents as inevitable is fatalistic. The objective of integrating the highest standards of health and safety with improved business performance means that the end product/ service must be achieved in a manner that protects employees and the public from harm. Operating to any less a standard will only guarantee a negative outcome and ensure that accidents continue. 2. Detail the changes needed. If changes have occurred then itemise them and consider how they will affect the operation. 3. List the improvement actions. Draw up an action plan, identifying the resources implications, managers responsible for completing the actions and the timescales for completion." Also you can see the full OAC model in an e-learning program at the following web address; http://www.confinedspaces.com/oac/index.htm Good luck Ciaran
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#8 Posted : 08 February 2002 10:26:00(UTC)
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Posted By Robert K Lewis Martin I think you are looking for a prompt to ask the right questions methodically and the broad heads HOW, WHAT, WHY etc are no guarantee. I actually use a tool called a comprehensive list of causes which was oil industry developed and may be used in any incident analysis. I will e-mail a copy of the questions in booklet form. I also have it as a chart with the questions abbreviated as this helps me to the Management System roots. Bob
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#9 Posted : 08 February 2002 10:27:00(UTC)
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Posted By Robert K Lewis Just realised you have not activated your e-mail address at the top. Can you supply it or a postal address Bob
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#10 Posted : 08 February 2002 14:41:00(UTC)
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Posted By Ian Waldram For a commercial product which is well-proven, see the details on the Taproot home page: www.taproot.com I find their process helpful, though it's a bit complex when applied to human factors - reflecting reality! Their software is good, allowing good diagrams of the root causes and with the capacity to distinguish between barriers which were ineffective, and those which missing.
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#11 Posted : 08 February 2002 15:57:00(UTC)
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Posted By Martin Many thanks for all your responses - extremely useful information. Robert, My e-mail address is martin.29@ntlworld.com. Thanks again!
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#12 Posted : 11 February 2002 14:07:00(UTC)
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Posted By Robert K Lewis Ian Reason also do a reasonable, excuse the pun, software which is more widely applicable! I find the report compiler attached to it a bit problematic though See www.rootcause.com Bob
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