Accident causation.pdfVIP

ACCIDENT CAUSATION Ramsgate Walkway Collapse Week 7 1 MAJOR HAZARDS MANAGEMENT Outline ? Generic sources of accident causes ? General accident analysis ? Detailed accident analysis – Ramsgate walkway collapse – Background – Investigation – Conclusions – Causes – Lessons learned – Consequences 2 Introduction ? Serious accidents continue to occur ? Professional engineers investigate the causes as engineering issues frequently arise ? There are lessons to be learnt ? Practically all accidents have multiple causes ? Each incident occurs when an appropriate combination of causes comes together at one time and place 3 Most common generic sources of causes ? Engineering problems, followed by ? Management problems ? Operator errors ? Environmental effects 4 General accident analysis ? Detailed study of 45 well-known reported accidents ? Drawn from a number of operating areas including – Railways, Ships, Aircraft, Power Stations, Chemical Process Plant, and Bridges and Structures ? Four major generic sources of accident causes identified, each with a number of subsections, totalling 14 sources – Management, Engineering, Operator Errors, Environmental Effects ? Analysis of the 45 accidents indicated contributions from 169 causes 5 Generic sources of causes with subsections 1. Management problems a. Time and financial constraints b. Lack of understanding of operational issues 2. Engineering problems a. Design defects b. Material defects c. Manufacturing process errors d. Poor quality maintenance e. Inadequate analysis of experience 3. Operator errors a. Lack of training b. Carelessness c. Tiredness or drug impairment d. Problems with the working culture 4. Environmental effects a. Weather and ambient conditions b. Plant layout interactions c. Potentially dangerous equipment and materials 6 Patterns of causes emerging between the operating areas 1. Engineering problems were the leading causes in all areas, followed by 2. Management Problems, particularly in Railway