ACCIDENT ANALYSIS AND INVESTIGATION Accident analysis procedure should include the following 1. To find out the source of accident from actual experience, cross questioning to coworkers and eye witness. 2. Describe the nature and size of accident problem in the department 3. To indicate engineering revision by identifying unsafe condition, material, and 4. 5. 6. 7.
equipment Disclose the unsafe practices for training of employee Disclose inefficient operating procedure and outdated method to reduce the accident Disclose the improper placement of person Guide the supervisor to spend more time in safety work and motivate among the
workers. 8. Evaluate the success of safety program by continuing analysis. The accident investigation process 1. Report the accident occurrence to a designated person within the organization 2. Provide first aid and medical care to injured person(s) and prevent further injuries or
damage 3. Investigate the accident
1. Interrogation with co-workers and eye witnesses 2. To collect Photograph, Sketches, notes record etc. 3. Fact should be collected ex. Testing, report, register, document defective or damage parts etc. 4. Check on the condition of any plant, machinery, equipment or chemicals – 5. 6. 7. 8.
this may involve specialist advice Interview injured persons when appropriate to do so Check on any previous accidents/incidents in the area Check on injured persons training records Obtain any necessary personal details of the injured person
4. Identify the causes 5. Report the findings 6. Develop a plan for corrective action 7. Implement the plan 8. Evaluate the effectiveness of the corrective action 9. Make changes for continuous improvement
Purpose/Aim
1. The main objective is to find the root causes of accident and suggest appropriate remedial measure to prevent the its recurrence instead of blaming and fault finding of 2. 3. 4. 5.
an individual To make known hazards and there consequence to the management. To find fact to determine legal liabilities and information for preventive purpose To establish procedure to combat damaging claim under various compensation rules. In case of an accident affecting the society then the government may banned that
6. 7. 8. 9.
hazardous activity process. To developed the safety rules, procedure, poster, motivation program To use record for the purpose of JSA. To find out injury rate to compare safety performance. To amend the safety law if it is necessary.
10. Identify and describe the true course of events (what, where, when) 11. Identify the direct and root causes / contributing factors of the accident (why) 12. Identify risk reducing measures to prevent future, comparable accidents (learning) 13. Investigate and evaluate the basis for potential criminal prosecution (blame) 14. Evaluate the question of guilt in order to assess the liability for compensation (pay) Agencies investigating accident 1. In case of statutory reportable accident , generally factory inspector investigate 2. Major, permanent, immediate responsibility of an accident investigation lies upon
factory management. 3. Depending upon the nature and gravity of accident, it may be investigated by
foreman, supervisor, safety engineer or officer. 4. In most cases, the supervisor should help investigate the event. Other members of
the team can include: 1. employees with knowledge of the work 2. safety officer 3. health and safety committee 4. union representative, if applicable 5. employees with experience in investigations 6. "outside" expert 7. representative from local government Benefits/Advantage of Accident Analysis 1. To find out the cause of accidents and to prevent similar accidents in the future. 2. To help in fulfil any legal requirements.
3. It Help to determine the cost of an accident. 4. To determine compliance with applicable safety regulations. 5. It also used to process workers' compensation claims. 6. Provide information for insurance purpose. 7. Monitoring status of implementation of safety measure. 8. Studying past accident causes and remedial measure concluded. 9. It used to help to take decision regarding future action in the matter of safety. 10. It used to find out injury rates to compare safety performance. 11. Reduce the number of accident and reduce the cost. 12. Improved product yield and maximize profit. 13. Reduce system development time and cost. 14. It helps to find out the violation of any safety law, unsafe action of people, needs
of training & motivation program to workers. 15. It helps to developed awareness among the people about consequence of accident.
Definition Accident analysis is carried out in order to determine the cause or causes of an accident or series of accidents so as to prevent further incidents of a similar kind. It is also known as accident investigation. Incident analysis is a structured process for identifying what happened, how and why it happened, what can be done to reduce the risk of recurrence and make care safer, and what was learned. CLASSIFICATION OF ACCIDENTS As pr IS 3786
The principal factors related to causation of accidents are:
Agency 1. Machine 2. Means of transportation 3. Other equipment i.e. furnace, refrigerating plant, pressure vessels 4. Material substance and radiation 5. Working environment. unsafe mechanical or physical condition, 1. Improperly guarded agency 2. Defects in agency 3. Hazardous arrangement, procedure 4. Improper illumination 5. Unsafe dress or apparel 6. Improper ventilation unsafe act 1. Operating without authority 2. failure to secure or warn 3. Operating at unsafe speed 4. Marking safety devices inoperative 5. Using unsafe equipment, hand instead of equipment, or equipment unsafely 6. Unsafe loading, placing, mixing, combining, etc 7. Taking unsafe position or posture unsafe personal factor 1. Unsuitable anatomical, physiological, or psychological characteristics 2. Lack of knowledge or skill type of accident 1. Fall of person 2. Fall of object 3. Caught between object 4. explosion nature of injury 1. Fracture 2. Dislocation 3. Amputation 4. burns Location of injury 1. Face 2. Head 3. Ear 4. Nose 5. Upper limb 6. Lower limb.
Reasons of why it is important to report the entire incident 1. Most importantly, to find out the cause of accidents and to prevent similar accidents
in the future 2. to fulfil any legal requirements 3. to determine the cost of an accident
4. to determine compliance with applicable safety regulations 5. to process workers' compensation claims
Need of accident Record 1. Monitoring status of implementation of safety measure. 2. Studying past accident causes and remedial measure concluded. 3. It used to help to take decision regarding future action in the matter of safety. 4. Records also help to prevent injuries and ill health, and control costs from accidental
loss. 5. Can be used as an aid to risk assessment, helping to develop solutions to potential
risks. 6. to fulfil any legal requirements 7. to process workers' compensation claims 8. For insurance purpose
Method of accident analysis and its advantage Silent feature of accident investigation Procedure followed for accident reporting MAH (Major Accident Hazard) Definition of Major Accident: “Major Accident” means an incident involving loss of life inside or outside the site or ten or more injuries inside and/or one or more injuries outside or release of toxic chemical or explosion or fire of spillage of hazardous chemical resulting in ‘on-site’ or ‘off-site’ emergencies or damage to equipments leading to stoppage of process or adverse effects to the environment.
Definition of Major Accident Hazard (MAH) Installation: "Major Accident Hazard (MAH) installation� means isolated storage and industrial activity at a site handling (including transport through carrier or pipeline) of hazardous chemicals equal to, or in excess of the threshold quantities specified in COLUMN 3 OF SCHEDULE 2 and SCHEDULE 3 respectively OF CHEMICAL ACCIDENT RULES 1996. Major Accident Hazard (MAH) identification: As per the schedule 1 2 3 of chemical rules 1989, prescribe the criteria for toxic flammable or explosive chemical , list out the hazardous chemical and give there threshold quantities. Thus the plant keeping the quantities more than or equal to the threshold quantities mentioned in the schedule 3 OR the isolated storing quantities more than or equal to threshold quantities mention in schedule 3 are to be identified major accident hazard unit. Based on above discussion the MAH unit mostly associated with 1. 2. 3. 4.
Storage/process of NH3 or LPG Petrochemical plant Pesticide factory Explosive factory & fertiliser plant
ROLE of MANAGEMENT 1. Proved the information to concerned authority about the criteria of quantities and hazardous process substance to identify the unit as an MAH unit 2. Carry out the safety audit and risk assessment report and submit to concerned authority in prescribe format for example Safety report as pr schedule 8, MSDS as pr 9, information of imported chemical 10, on site and off site emergency plant as per 11 and 12 respectively 3. Collection, development and dissemination of information 4. Provide on-site and of- site emergency plan based on guideline of factory inspector 5. Provide safety measure to prevent the major accident and there consequences 6. Provide safety training to workers 7. Keep update the information of changes in threshold quantity of hazardous chemical. 8. Provide information to the public liable to be affected by major accident. 9. Inform within 48 hour to concerned authority if any major accident happen. 10. Inform within 30 days to concerned authority for the importation of any hazardous chemical 11. Maintain and keep the record of imported hazardous chemical ROLE OF GOVERMENT 1. To Enact, Implement and amend the law on major hazard control
2. To require statutory information from industries to identify the unit as MAH unit in the form of safety report and on site and off site emergency plan 3. To compile data of MAH unit sate wise, district wise, nation-wide with the list of MAH factory, hazardous chemical, process, type, quantities, and consequences 4. Provide the Valuable information to MAH management and to the workers and general public also. 5. To set central crisis alert system as per rule 4 of chemical accident rule 1996 6. To establish and maintain the inventory of MAH unit based on safety report and location of unit with respect to population 7. To inspect the MAH unit to based on safety report received to check the correctness and effectiveness of safety arrangement provided 8. To draw up off site emergency plan after consultation with MAH unit. Agency may include police, hospital, telephone, fire brigade, etc 9. To provide safety checklist to evaluate safety measure and developed inspection system and program 10. To make and implement Siting policy to separate MAH unit from other unit and population. ROLE OF PUBLIC/LOCAL AUTHORITY 1. They should know their roles at the time of off-site emergency plan. For this purpose they should attend the meeting with authority and factory management to clear their doubts and duties 2. At time of off-site emergency plan they should follow the instruction whether to stay at home or be prepared for evacuation. 3. The injured people should immediate take the medical help or antidote suggested by the doctor. 4. Public should give full co-operation at the time of emergency. 5. They should not cause obstruction, hindrances or difficulties at the time of emergency Discuss Major Hazards Control System
Definition: “Major Accident” means an incident involving loss of life inside or outside the site or ten or more injuries inside and/or one or more injuries outside or release of toxic chemical or explosion or fire of spillage of hazardous chemical resulting in ‘on-site’ or ‘off-site’ emergencies or damage to equipments leading to stoppage of process or adverse effects to the environment.
Objective-
1. To distinguishes between major and minor hazards and set the priority of identification and inspection of major hazards 2. To define hazardous chemical by defining their fire, explosion and toxicity criteria and define their threshold quantities for storage and use 3. To define and list the hazardous process to identify the unit for MAH Installation 4. To make, enact, implement the law for MAH chemical works and isolated storage by providing statutory provision and requirement. 5. To identify the major hazard by developing and utilising various techniques such as ETA,FTA, HAZOP, vulnerability analysis etc 6. To take all the preventive measure based on identified major hazard to prevent consequences of major accident. 7. Work out on action emergency plan. 
Components1. Define and identify the MAH Installation 2. Information about MAH installation. e.g. safety report and safety manual 3. Assessment of major hazards by competent person to identify the cause, their consequences and suggest preventive measure. 4. Control the cause of major industrial accident by sound engineering and 5. 6. 7. 8.
management principal Onsite and offsite emergency plan Siting and land uses planning Safe operation of major hazard installation by training to worker. To inspect MAH plant by plant management or government authority.
CONTROL MASURE OF MAH 1. By keeping the quantities hazardous chemical not more than the threshold quantities mentioned in the schedule 3 OR the isolated storing quantities not more than threshold quantities mention in schedule 3. 2. Carry out the safety audit and risk assessment to identify the major hazard. 3. Prepare the on-site and of- site emergency plan based on guideline of factory inspector 4. To identify the major hazard by developing and utilising various techniques such as ETA,FTA, HAZOP, vulnerability analysis etc 5. Provide safety measure to prevent the major accident and there consequences 6. Provide safety training to workers 7. Keep update the information of changes in threshold quantity of hazardous chemical. 8. Provide information to the public about the offsite emergency plan. 9. To set central crisis alert system as per rule 4 of chemical accident rule 1996. 10. To take all the preventive measure based on identified major hazard to prevent consequences of major accident. 11. Prepare the safety checklist to evaluate the safety measure 12. For safe operation of MAH installation should pay the attention ona. Design, manufacturing and assembly of the component
b. Process control c. Safety system( Sensor controller, pressure relief, emergency shutdown, d. e. f. g.
bunds water spray, fire detector etc) Monitoring the safety related component and system. Inspection, maintenance and repair Training of workers Supervision and control of contract work.
ILO CODE OF PRACTICES FOR MAJOR ACCIDENT HAZARD CONTROL C174 - Prevention of Major Industrial Accidents Convention, 1993 PREAMBLE 1.
Having been convened at Geneva by the Governing Body of the International
Labour Office, and having met in its 80th Session on 2 June 1993. 2. It has 7 parts and 30 articles. PART I. SCOPE AND DEFINITIONS 1.
The purpose of this Convention is the prevention of major accidents involving
hazardous substances and the limitation of the consequences of such accidents. 2. This Convention applies to major hazard installations. 3. Article 3 defines the hazardous substance, threshold quantity, major hazard installation, major accident, safety report, and near miss. PART II. GENERAL PRINCIPLES (Article1-3) 1. Shall formulate, implement and periodically review a coherent national policy concerning the protection of workers, the public and the environment against the risk of major accidents. PART III. RESPONSIBILITIES OF EMPLOYERS (Article4-6) 1. Identification- Employers shall identify any major hazard installation 2. Notification of installation- Employers shall notify the competent authority of any major hazard installation 3. Arrangement of installation- employers shall establish and maintain a documented system of major hazard control 4. Safety report - Employers shall prepare a safety report based on the requirements of Article 9. Employers shall review, update and amend the safety report: 5. Accident reporting- Employers shall inform the competent authority and other bodies as soon as a major accident occurs. PART IV. RESPONSIBILITIES OF COMPETENT AUTHORITIES (Article 7-14)
1. Off-Site emergency plan 2. Siting of major hazard installation 3. Inspection PART V. RIGHTS AND DUTIES OF WORKERS AND THEIR REPRESENTATIVES (Article15-19) PART VI. RESPONSIBILITY OF EXPORTING STATES (Article 22) PART VII. FINAL PROVISIONS (Article23-30) Supplement to above convention, recommendation was adopted on the same day which provides for exchange of information with ILO on safety management, process safety, and major accident. Near misses, technical and medical control measure Methods of Hazard Assessment To achieve the aims of a hazard assessment, it is necessary to follow certain procedures or use certain aids. A number of working methods have been developed for this purpose. These are summarised below 1. Preliminary hazard analysis (PHA) 2. Hazard and operability study (HAZOP) 3. Failure mode and effect analysis 4. Fault tree analysis 5. Event tree analysis 6. Maximum creditable assessment analysis 7. Vulnerability analysis 8. What if analysis 9. Accident sequence analysis 10. Accident consequences analysis 11. Safety checklist 12. Safety audit and safety report 13. Job safety analysis Responsibilities of MAH at Local level 1. prepare local emergency plan for the industrial pocket; 2. train personnel involved in chemical accident management; 3. ensure dovetailing of the local emergency plan with the district off-site emergency plan; 4. Educate the population likely to be affected in a chemical accident about the remedies and existing preparedness in the area. 5. conduct at least one full scale mock-drill of a chemical accident at a site every six months forward a report to the District Crisis Group; 6. Respond to all public inquiries on the subject.
Responsibilities MAH at State level 1. To provide expert guidance for handling major chemical accidents. 2. continuously monitor the post accident situation arising out of a major chemical accident and suggest measures for 3. review the progress reports submitted by the State Crisis Groups; 4. post-accident analysis of such major chemical accidents and evaluate responses; 5. Review district off-site emergency plans with a view to examine its adequacy in accordance with the Manufacture, Storage and Import of Hazardous Chemicals, Rules, and suggest measures to reduce risks in the Industrial pockets; 6. Respond to queries addressed to it by the State Crisis Groups and the District Crisis Groups; 7. Publish a State-wise list of experts and officials render, 8. assist the State Government in the planning, preparedness and mitigation of major chemical accidents at a site in the State; 9. continuously monitor the post accident situation arising out of a major chemical accident in the State and forward a report to the Central Crisis group; 10. review the progress report submitted by the District Crisis groups; 11. respond to queries addressed to it by the District Crisis groups 12. Publish a list of experts and officials in the State who are concerned with the management of chemical accidents MAJOR HAZARD CONTROL SYSTEM AT NATIONAL LEVEL After the Bhopal tragedy a series of legislative and organisational measures have been instituted by the Government of India to control major accidents and safeguard public life and property from hazards of the chemical industry. 1. Legislative Measure The concern of the Government of India has been reflected in amending the Factories Act, 1948 in 1987 and enacting the Environment (Protection) Act, 1986. Subsequently the following regulations came into effect: 1. The Manufacture, Storage and Import of Hazardous Chemicals (MSIHC) Rules, 1989 and its amendments in 1990 and 1994. 2. The Chemical Accidents (Emergency Planning, Preparedness and Response) Rules, 1996. 3. The Hazardous Wastes (Management & Handling) Rules, 1989. 4. The Environment Impact Assessment Notification, 1994 2. Establishment of a Major Accident Hazards Control System in India
3. Identification of MAH Factories/Installations- MAH Factories/Installations in India has been identified based on specified substances and their threshold quantities as per the MSIHC Rules, 1989. 4. Formation of Crisis Groups- Government of India launched a programme of pocketwise industrial hazard identification and risk analysis with the objective of risk reduction and development of risk minimisation plans for MAH installations 5. Establishment of Management Information System in MAH Factories/Installations Discuss which agencies, organisation and authorities should be included in major hazard emergency control at city level, state level, and national level?