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Workplace Health, Safety and Risk EC214C ,[object Object],[object Object],[object Object],[object Object],[object Object]
Contact details ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Module Objectives ,[object Object],[object Object],[object Object],[object Object],[object Object]
Module documents ,[object Object],[object Object],[object Object],[object Object]
Content ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Content ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],Assessment
2010 ACW (RTB) – advance information (may be an addition) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
2010 ACW ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Basic steps in risk assessment Classify work activities Identify hazards  Determine risk Decide if risk is tolerable Prepare risk control action plan Review adequacy of action plan
 
 
 
 
 
 
Labourer fatally injured in a Quarry Conveyor ,[object Object],[object Object],[object Object]
 
Quarry conveyor – causal factors ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Lessons to be learnt ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Traditional, reactive, approach to health & safety management ,[object Object],[object Object],[object Object],[object Object]
Traditional Safety Management ACCIDENT Investigate accident - steered by the preconceptions of the investigator Attribute primary cause to unsafe acts Attribute primary cause to unsafe conditions RULE  devised forbidding unsafe acts TECHNICAL solution to make conditions safe
Causation debate missed: ,[object Object],[object Object],[object Object]
Prevention founded on accident investigation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Time Perception of risk Perceptions of risk and prevention
Time Perception of risk Serious accident Perceptions of risk and prevention
Time Perception of risk Serious accident Rules and safeguards devised here  may be  violated  when perceptions decay over  time   Perceptions of risk and prevention
Accident causation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Events and Outcomes ws Near miss Hazard Fatality Property damage Major   injury Minor injury Event Accident             Incident OUTCOME Environmental  damage
The Accident Triangle Major or >3 day injury Minor injury Non injury 189 7 1
Hale and Hale Model –  behaviour in the face of danger Action Presented Information Expected Information Perceived Information Possible Actions Cost / Benefit Decision
Human Failure Knowledge- based Rule-based Lapses Slips Exceptional Skill-based (unintended) Errors Situational Mistakes (intended action * ) Routine Violations (intended) *   But unintended diagnostic error Reason’s error type classification - ve Safety Culture
 
 
 
Mini assignment ,[object Object],[object Object],[object Object],[object Object]
Initial Status Review OHS Policy Management Review Planning Checking &  corrective action Implementation & operation Continual  improvement
The Main Elements in HSG65 Organising Planning and Implementing Measuring Performance Policy Reviewing Performance Auditing
Management system BS 18004: 2008 Initial Status Review OHS Policy Management Review Planning Checking &  corrective action Implementation & operation Continual  improvement
Safety management & culture ,[object Object],[object Object],[object Object]
Reactive to Proactive - Safety Improvement Stages Risk Indicators Time & Effort Safety Culture Regulation Lead Management Lead People Lead
Definition of Safety Culture HSG65 ‘97 ,[object Object],[object Object]
British Standard BS8800: 2004 ,[object Object]
Safety culture ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
What promotes a positive safety culture? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
BS8800: 2004  ,[object Object],[object Object],[object Object],[object Object]
Anecdotes – culture ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Measuring safety culture ,[object Object],[object Object],[object Object],[object Object],[object Object]
Positive safety culture objectives ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object]
Risk Assessment Law ,[object Object],[object Object],[object Object],[object Object],[object Object]
Management of Health & Safety at Work Regulations ,[object Object],[object Object],[object Object],[object Object]
Hazard-specific regulations ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Industry-specific regulations ,[object Object],[object Object],[object Object],[object Object],[object Object]
Basic steps in risk assessment Classify work activities Identify hazards  Determine risk Decide if risk is tolerable Prepare risk control action plan Review adequacy of action plan
Key terms ,[object Object],[object Object],[object Object],[object Object],[object Object]
Types of assessment – note overlap ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Classify work activities
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Identify hazards
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Determine risk
[object Object],[object Object],[object Object],[object Object],[object Object],Determine risk
[object Object],[object Object],[object Object],[object Object],Decide if risk is tolerable
Risk level Estimator Highly Unlikely Likely Unlikely Harmful Slightly Harmful Extremely Harmful TRIVIAL RISK MODERATE RISK MODERATE RISK MODERATE RISK SUB- STANTIAL RISK INTOLERABLE RISK TOLERABLE RISK TOLERABLE RISK SUB- STANTIAL RISK
[object Object],[object Object],[object Object],Prepare risk control action plan
Risk-based control plan RISK LEVEL ACTION (AND TIMESCALE) TRIVIAL No action, no records TOLERABLE No further action necessary: monitor to ensure controls maintained   MODERATE Efforts to reduce risk, but costs of prevention should be limited SUBSTANTIAL Urgent efforts to reduce risk: reduction costs may be high INTOLERABLE Work should not be started or continued until risk reduced: no cost constraints for prevention
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Prepare risk control action plan
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Review adequacy of action plan
Critique of three-point scales ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Likelihood of Hazardous Event ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Rate Hazardous Event ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Severity ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Assessing Risks ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Risk Matrix ,[object Object],[object Object],[object Object],[object Object],[object Object]
Risk Matrix Extreme 36 30 24 18 12 6 6 Very high 30 25 20 15 10 5 5 High 24 20 16 12 8 4 4 Low 18 15 12 9 6 3 3 Very low 12 10 8 6 4 2 2 Insignificant 6 5 4 3 2 1 1 Risk levels 6 5 4 3 2 1 Likel ihood Severity
Risk Control ,[object Object],[object Object],[object Object]
Deciding on Risk Reduction ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
 
[object Object]
‘ Advanced’ Risk Assessment ,[object Object],[object Object],[object Object],[object Object],[object Object]
Advanced Risk Assessment Techniques ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Steps in advanced risk assessment Cost-Benefit Analysis DEFINE  SYSTEM   IDENTIFY HAZARDS  HAZARDOUS EVENTS  HAZARDS EVENTS CONTINUING HAZARDS  ANALYSE  CONSEQUENCES DECIDE  RISK CONTROL  STRATEGY VERIFY ESTIMATE/  MEASURE RISKS EVALUATE  RISKS NO CHANGE  (MONITOR) YES NO IS RISK   TOLERABLE? Task-based approach HAZOPS FMEA CHECK-LIST Event Tree Analysis Fault Tree Analysis Event Tree Analysis   C Hierarchy Risk Matrix or  Risk Calculator 1 in  10 ,000 1 in 1m QRA
 
 
 
 
Hazard and Operability Studies ‘HAZOPS’ ,[object Object],[object Object],[object Object]
Principle of HAZOPS INTENTION DEVIATIONS Possible Causes Potential Consequences
HAZOPS Methodology ,[object Object],[object Object],[object Object],[object Object],[object Object]
HAZOPS Methodology ,[object Object],[object Object],[object Object],[object Object],[object Object]
NO MORE LESS OTHER THAN GUIDE WORDS Principle of HAZOPS INTENTION DEVIATIONS Possible Causes Potential Consequences Inductive logic Deductive logic
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],possible causes process deviations possible consequences
Guide Words Property ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Typical problems revealed with guide words ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Typical problems revealed with guide words ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Typical problems revealed with guide words ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Exercises Metal cleaning shop
Metal cleaning shop Design intention ,[object Object],[object Object],[object Object],[object Object]
Divide system into lines & tanks Local Extract Ventilation Design intention:  to   provide constant face velocity 5m/sec Fan Filters Face velocity 5 m/sec
No Flow  Power fails  Increased  None  A  Consider emergency concentration  power supply
 
HAZOP WORK-SHEET Storage tank  T-1 To store flammable reagent at 1.1 bar and 20° C G UIDE  W ORD PROPERTY P OSSIBLE  C AUSES C ONSEQUENCES A CTION  R EQUIRED MORE LEVEL 1. Pump P-1 fails to stop Reagent released Incorporate high level alarm and trip 2. Reverse from process Reagent released Consider check valve Line 2 LESS 3. Pump P-1 cavitates Damage to P-1 Can reagent explode? If pump overheats? 4. Rupture in Line 2 Reagent released Consider alarm and pump shut-down 5. V-3 open Reagent  released Consider alarm 6. V-1 open Same Same 7. Tank rupture Same What external events can cause rupture? NO Same as  LESS OTHER THAN COM – 8.Wrong reagent Possible reaction Is reagent sampled before POSITION pumping ? AS WELL AS 9.Impu rity in reagent Possible overpressure, if What are the possible volatile impurities? LESS PRESSURE 10. Break in flare or  Reagent released Consider low pressure alarm nitrogen lines 11. Loss of nitrogen Tank implodes What i s design vacuum of tank ? 12. CV-2 fails closed Tank implodes 13. PIC fails Tank implodes MORE 14. PIC fails Reagent released via R.valve What is capacity of  CV-1  R. valve? 15. CV-1 fails closed Reagent released via Relief 16. V-7 c losed Same as (15) Is  V-7 locked open? 17. Overfill tank See (6) Is  V-8 locked open?
Failure Modes and Effects Analysis ‘FMEA’ ,[object Object],[object Object],[object Object]
Steps in advanced risk assessment Cost-Benefit Analysis DEFINE  SYSTEM   IDENTIFY HAZARDS  HAZARDOUS EVENTS  HAZARDS EVENTS CONTINUING HAZARDS  ANALYSE  CONSEQUENCES DECIDE  RISK CONTROL  STRATEGY VERIFY ESTIMATE/  MEASURE RISKS EVALUATE  RISKS NO CHANGE  (MONITOR) YES NO IS RISK   TOLERABLE? Task-based approach HAZOPS FMEA CHECK-LIST Event Tree Analysis Fault Tree Analysis Event Tree Analysis   C Hierarchy Risk Matrix or  Risk Calculator 1 in  10 ,000 1 in 1m QRA
 
FMEA analytical procedure ,[object Object],[object Object],[object Object],[object Object],[object Object]
FMEA analytical procedure ,[object Object],[object Object],[object Object],[object Object]
Example: Chlorine storage system Pressure switch Storage tank Relay Pump Valve PT
Details of pressure switch design Pressure Bellows Micro-switch Pivot Spring Beam PRESSURE SWITCH Pressure switch Storage tank Relay Pump Valve PT
Details of the transmitter design: Normally Open relay Pressure switch Storage tank Relay Pump Valve PT
FMEA: estimation and evaluation of risks A B C D E I II III IV Probability level Medium Medium risk risk High risk High risk RP1 RP1 RP3 RP3 Low risk Low risk RP2 RP2 Medium Medium risk risk Severity Category A B C D E Probability level 10 -1 10 -2 10 -3 10 -4 10 -5 Description I II III IV Severity category Minor Critical Major Catastrophic Degree Functional failure –  minor injury/ ill health No major damage or  serious injury Major damage and/or  potential serious injury Complete system loss  and/or potential fatality Description Probability value Frequent Probable Occasional Remote Improbable
 
FMEA: worksheet
FMEA: summary sheet Rank failure modes according to criticality; Decide actions required to reduce risks; Design measures should be considered as a priority
Normally open (NO) cam-activated electrical switch Guard Guard closed closed Guard Guard open open Hazard Hazard
Normally closed (NC) cam-activated electrical switch Guard Guard closed closed Guard Guard open open Hazard Hazard
Cam operated electrical limit switches
Event Tree Analysis ‘ETA’ ,[object Object],[object Object],[object Object],[object Object]
Steps in advanced risk assessment Cost-Benefit Analysis DEFINE  SYSTEM   IDENTIFY HAZARDS  HAZARDOUS EVENTS  HAZARDS EVENTS CONTINUING HAZARDS  ANALYSE  CONSEQUENCES DECIDE  RISK CONTROL  STRATEGY VERIFY ESTIMATE/  MEASURE RISKS EVALUATE  RISKS NO CHANGE  (MONITOR) YES NO IS RISK   TOLERABLE? Task-based approach HAZOPS FMEA CHECK-LIST Event Tree Analysis Fault Tree Analysis Event Tree Analysis   C Hierarchy Risk Matrix or  Risk Calculator 1 in  10 ,000 1 in 1m QRA
Fire protection system ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
“ FIRE” “ FIRE” Fails Fails Success Major Major Fire A A B B C C D D E E Initiating event Detector Valve Water  supply  Success Success Alarm Major fire Major fire Possible fatalities Possible fatalities Sprinkler might Sprinkler might work work Evacuation of Evacuation of personnel personnel No sprinkler No sprinkler protection protection
Quantification of Event Trees ,[object Object],[object Object],[object Object]
“ FIRE” “ FIRE” Fails Fails Success P = 0.1 P = 0.1 P = 0.90 P = 0.05 P = 0.05 P = 0.95 P = 0.9 P = 0.1 P = 0.1 P = 0.95 P = 0.05 P = 0.05 P=0.731 Evacuation of Evacuation of personnel personnel No sprinkler No sprinkler protection protection P=0.1 Major fire Possible fatalities Sprinkler  might work Major Fire A A B B C C D D E E Initiating Event Detector Valve Water  supply  Success Success Alarm
Calculation of risk ,[object Object],[object Object],[object Object]
Major fire Possible fatalities Sprinkler  might work Major Fire Initiating Event Detector Valve Water  sprinkler  Alarm ƒ = 0.1/yr  ƒ = 0.0731 /yr   ƒ = 0.01/yr “ FIRE” “ FIRE” Fails Fails Success P = 0.1 P = 0.1 P = 0.90 P = 0.05 P = 0.05 P = 0.95 P = 0.9 P = 0.1 P = 0.1 P = 0.95 P = 0.05 P = 0.05 Evacuation of Evacuation of personnel personnel No sprinkler No sprinkler protection protection A A B B C C D D E E Success Success
Fault Tree Analysis ‘FTA’ ,[object Object],[object Object],[object Object],[object Object],[object Object]
Steps in advanced risk assessment Cost-Benefit Analysis DEFINE  SYSTEM   IDENTIFY HAZARDS  HAZARDOUS EVENTS  HAZARDS EVENTS CONTINUING HAZARDS  ANALYSE  CONSEQUENCES DECIDE  RISK CONTROL  STRATEGY VERIFY ESTIMATE/  MEASURE RISKS EVALUATE  RISKS NO CHANGE  (MONITOR) YES NO IS RISK   TOLERABLE? Task-based approach HAZOPS FMEA CHECK-LIST Event Tree Analysis Fault Tree Analysis Event Tree Analysis   C Hierarchy Risk Matrix or  Risk Calculator 1 in  10 ,000 1 in 1m QRA
[object Object],Explosive concentration Temperature to ignite EXPLOSION Ignition source Energy to ignite AND 1st level 2nd level 3rd level OR OR OR OR TOP EVENT Heated surfaces Naked flame Electro- static Sparks generated
The ‘OR’ Gate ARRIVE  LATE  A WAKE  UP LATE  X DELAYED  EN ROUTE  Y INCORRECT  TIME  Z TOP EVENT  (OUTPUT) INPUT  EVENTS Event ‘A’ occurs if (at least) one of  X  OR  Y  OR  Z  occurs OR
The ‘AND’ Gate Event ‘A’ occurs if both  X  AND  Y  occur
FTA –lighting system Fuse Switch Bulb 1 Bulb 2 Power  Source Room dark Power off Power  supply failed Switch open Fuse Blown Both bulbs burned out Bulb 1 burned out Bulb 2 burned out
Risk Assessment Methodologies Human Reliability Analysis  (HRA) Richard Booth
Machine/  P rocess CONTROLS Display H UMAN- M ACHINE  I NTERFACE
Human error rates
Human Error as a function of stress level Error Rate Stress Level Bored Over-excited
Hierarchical Task Analysis ‘HTA’ A process of developing a description of a task in terms of operations - things which people should do and plans - statements of conditions when each task/step has to be carried out
[object Object],[object Object],Prepare a cup of medium sweet tea Prepare cup and tea bag 1 2 3 4 5 Switch ON kettle Pour boiling water on tea bag Add milk to correct concentration Add one spoon of sugar
Example: Wiring three-pin plug ,[object Object],[object Object],[object Object],[object Object],[object Object]
 
 
Hierarchical Task Analysis ‘HTA’ 0 WIRE A THREE  PIN PLUG 1 PREPARE PLUG 2 PREPARE  CABLE 3 4 TEST PLUG 2.1 CUT & STRIP   OUTER CABLE   SHEATH  2.2 2.3 CARRY OUT  ASSEMBLY 3.2 3.3 3.4 SELECT AND FIT   13 Amp FUSE 3.5 TIGHTEN CABLE   STRIP & REPLACE   COVER Plan 0: do in order Plan 2: 1 then 2 then 3 Plan 3:  1,2,3,4 then 5 CUT & STRIP   INDIVIDUAL WIRES   AS MARKED TERMINATE ALL   3 WIRE STRANDS 3.1 FIT BLUE WIRE   IN TERMINAL 1 &   TIGHTEN SCREW FIT YELLOW WIRE   IN TERMINAL 2 &   TIGHTEN SCREW FIT BROWN WIRE IN   TERMINAL 3 &   TIGHTEN SCREW
 
Risk Decision-making
Tolerability decisions ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Definitions ,[object Object],[object Object],[object Object],[object Object]
Definitions ,[object Object],[object Object],[object Object],[object Object]
HSE ‘ALARP’ Intolerable Risk Upper Limit Lower Limit Negligible As Low As Reasonably Practicable ‘ALARP’ Broadly acceptable
HSE ‘ALARP’  Intolerable Risk Upper Limit: 1 in 1,000 (workers) 1 in 10,000 (public) Risk of death / year Lower Limit: 1 in a million (workers & public) Risk of death / year Negligible As Low As Reasonable Practicable ‘ALARP’ Broadly acceptable
Definition ,[object Object],[object Object],[object Object]
The Statistics of Risk - presentation of risk data ,[object Object],[object Object],[object Object],[object Object]
Death as an annual experience Cause of Death chance/year All causes Overall average 55-64 men women 35-44 men women 5-14 boys girls Hang gliding Road accidents Gas explosion (home) Electrocution (home) Lightning 1 in 87 1 in 65 1 in 110 1 in 578 1 in 873 1 in 4,400 1 in 6,250 1 in 670 1 in 10,200 1 in 1 million 1 in 1 million 1  in 10 million
Death as an annual experience Cause of Death chance/year Work Accidents deep sea fishing extraction oil / gas construction agriculture all manufacturing 1 in 750 1 in 990 1 in 10,200 1 in 13,500 1 in 53,000
Death as a consequence of an activity Activity Chance of death Travel for 100,000 km by motor bike by pedal cycle by car by rail by bus by air Balloon (Atlantic) Pregnancy Anaesthesia 1 in 100 1 in 200 1 in 2,200 1 in 9,000 1 in 22,000 1 in 44,000 1 in 3 1 in 13,000 1 in 25,000
Average loss of life expectancy as a consequence of an activity Cause Loss of Life Expectancy (days) Being unmarried (male) Smoker (male) Being unmarried (female) Smoker (female) Dangerous job Vehicle accidents Homicide Average job Medical X rays Coffee drinking Reactor accidents Nuclear industry Smoke alarm Mobile coronary-care units 3,500 2,250 1,600 800 300 207 90 74 6 6 0.2 to  2 0.2 -10 -125
CBA Rational method ,[object Object],[object Object]
Cost-benefit model Cost £ Number of accidents Cost prevention - Employer Cost accidents - Employer Total Costs - Employer ‘ Optimum’ performance - Employer
Public perceptions: key issues ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],Public perceptions of risk: expert criticisms
Lay risk estimates
Public perceptions of risk: expert criticisms ,[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],Public perceptions of risk: expert criticisms
Media influences ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Risk-averse litigious society ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Trust and competence; Erosion of public confidence ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],Trust and competence; Erosion of public confidence
[object Object],[object Object],Trust and competence; Erosion of public confidence
[object Object],[object Object],Trust and competence; Erosion of public confidence
[object Object],[object Object],Measurement: public perceptions of risk
Examples ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
League Women voters College students Active club members Experts Nuclear power 1 1 8 20 Motor vehicles 2 5 3 1 Handguns 3 2 1 4 Smoking 4 3 4 2 Motorcycles 5 6 2 6 Alcoholic drinks 6 7 5 3 Private aviation 7 15 11 12 Police work 8 8 7 17 Pesticides 9 4 15 8 Surgery 10 11 9 5 Firefighting 11 10 6 18 Large construction 12 14 13 13 Hunting 13 18 10 23 Spray cans 14 13 23 26 Mountain climbing 15 22 12 29 Bicycles 16 24 14 15 Commercial aviation 17 16 18 16 Electricity (non-nuclr) 18 19 19 9 Swimming 19 30 17 10 Contraceptives 20 9 22 11 Skiing 21 25 16 30 X-rays 22 17 24 7 Football 23 26 21 27 Railroads 24 23 20 19 Food preservatives 25 12 28 14 Food colouring 26 20 30 21 Power mowers 27 28 25 28 Antibiotics 28 21 26 24 Home appliances 29 27 27 22 Vaccinations 30 29 29 25
 
Fragmentiser risk tolerability case study
Fragmentiser description and hazards ,[object Object],[object Object],[object Object],[object Object],[object Object]
 
 
 
 
Data required or assumed ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Action: ALARP and intolerable risks ,[object Object],[object Object],[object Object],[object Object]
Fragmentiser - perceptions ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Factors that affect public judgments of risk ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Data required or assumed ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Changing public attitudes ,[object Object],[object Object],[object Object],[object Object]
Changing public attitudes ,[object Object],[object Object],[object Object],[object Object]
[object Object]
Accident Analysis - Overview ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Change Analysis: fall in Victoria Square No recognition of changed circumstances /route Walking/observing on ‘autopilot’ Walking/observing on ‘autopilot’ Attention directed to stall produce Market stalls a significant distraction No unusual ‘distractions’ Also, carrying a shoulder bag and rucksack Pedestrians difficult to navigate around Pedestrians few and no effort to navigate around Diversion necessary from normal route (one step to descend) Frankfurt ‘Christmas’ Market in operation No physical barriers for normal route (and no steps) Anxiety about Course Stress state ‘elevated’ Stress state ‘normal’ Result of dealing with arrangements for AI Course at last minute More preoccupied than usual when going to catch (the) train Preoccupied when going to catch a train Indicates that IP (me) was not walking unduly fast, as was the case Time to get to station 35m Time to get to station 30m Comments Accident situation Normal Situation
Change Analysis: fall in Victoria Square - consequences Emergency admission to hospital suffering from whiplash injuries three days later  Fall on unseen step, and arrival at station bloody and shaken Delegates at AI course impressed by this Change Analysis!  Safe arrival at station Situational violation (need to catch the train) Cancelled ambulance despite police advice (and not given necessary treatment) Accept full first aid treatment Comments Accident situation Normal Situation
Investigation Purposes ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Role of Analytical Investigation - Summary ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Investigator Bias ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Effects of Inadequate Investigation ,[object Object],[object Object],[object Object],[object Object]
Activity Phases in Investigations ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Exercise: FLT Fatal Accident ,[object Object],[object Object],[object Object]
Accident Scene Warehouse X Racking Victim FLT Offices
Fatality due to FLT collision & FLT Collides with person & Victim Dies Person in the FLT Path FLT Fails to Stop Not aware of Need to Stop Aware but unable to Stop Driver actually Ill Driving Too fast Faulty Brakes Not Aware of Person Thinks person will evade 1 Person Aware of FLT Unaware of FLT Thinks FLT will Evade Unable to move out of way Person actually Ill Person Slips/trip Falls Disabled Time too short & Person Did Not See FLT Person Did Not Hear FLT 2 3 Poor visibility Vision obstructed Not looking Reversing Person Conspicuity Poor visibility Vision obstructed Not looking visually impaired FLT Conspicuity Wearing PPE Noisy place FLT quiet Wearing stereo Hearing impaired FLT Accident Investigation
Events and Casual Factors Analysis - Purposes ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Events and Casual Factors General Format Systemic Factors Contributing Factors Systemic factors Contributing factors Secondary events Primary events
ECF Chart Format ,[object Object],[object Object],[object Object],[object Object],[object Object]
ECF Chart Format (cont) ,[object Object],[object Object],[object Object],[object Object]
Events & Conditions Criteria ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Runaway Truck ECFA
 
 
 
Labourer fatally injured in a Quarry Conveyor ,[object Object],[object Object],[object Object]
 
[object Object],[object Object],[object Object]
 
 
 
Northern Tower: Window Cleaner fatally injured by Roof Hoist Cleaning Machine ,[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object]
 
[object Object],[object Object]
Objectives ,[object Object],[object Object],[object Object]
Objectives ,[object Object],[object Object],[object Object],[object Object],[object Object]
Key immediate events ,[object Object],[object Object],[object Object],[object Object],[object Object]
 
 
 
 
 
 
Proximate causal factors ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Note: Key people ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Note: Key people ,[object Object],[object Object],[object Object],[object Object],[object Object]
Key Oilco systems ,[object Object],[object Object],[object Object]
Root causes ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Overall Interface ,[object Object],[object Object],[object Object]
Planning maintenance work ,[object Object],[object Object],[object Object]
Method statements and risk assessments on-shore ,[object Object],[object Object],[object Object],[object Object],[object Object]
P2W / risk assessments off-shore ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
P2W / risk assessments off-shore ,[object Object],[object Object],[object Object]
Monitoring compliance ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Uncertainties ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
ECFA ,[object Object],[object Object],[object Object]
 
FTA ,[object Object],[object Object],[object Object],[object Object]
FTA ,[object Object],[object Object],[object Object]
 
Revision ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Concluding remarks

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Rtb wkplace health, safety & risk 2010 v f 01 12-10

  • 1.
  • 2.
  • 3.
  • 4.
  • 5.
  • 6.
  • 7.
  • 8.
  • 9.
  • 10. Basic steps in risk assessment Classify work activities Identify hazards Determine risk Decide if risk is tolerable Prepare risk control action plan Review adequacy of action plan
  • 11.  
  • 12.  
  • 13.  
  • 14.  
  • 15.  
  • 16.  
  • 17.
  • 18.  
  • 19.
  • 20.
  • 21.
  • 22. Traditional Safety Management ACCIDENT Investigate accident - steered by the preconceptions of the investigator Attribute primary cause to unsafe acts Attribute primary cause to unsafe conditions RULE devised forbidding unsafe acts TECHNICAL solution to make conditions safe
  • 23.
  • 24.
  • 25. Time Perception of risk Perceptions of risk and prevention
  • 26. Time Perception of risk Serious accident Perceptions of risk and prevention
  • 27. Time Perception of risk Serious accident Rules and safeguards devised here may be violated when perceptions decay over time Perceptions of risk and prevention
  • 28.
  • 29. Events and Outcomes ws Near miss Hazard Fatality Property damage Major injury Minor injury Event Accident             Incident OUTCOME Environmental damage
  • 30. The Accident Triangle Major or >3 day injury Minor injury Non injury 189 7 1
  • 31. Hale and Hale Model – behaviour in the face of danger Action Presented Information Expected Information Perceived Information Possible Actions Cost / Benefit Decision
  • 32. Human Failure Knowledge- based Rule-based Lapses Slips Exceptional Skill-based (unintended) Errors Situational Mistakes (intended action * ) Routine Violations (intended) * But unintended diagnostic error Reason’s error type classification - ve Safety Culture
  • 33.  
  • 34.  
  • 35.  
  • 36.
  • 37. Initial Status Review OHS Policy Management Review Planning Checking & corrective action Implementation & operation Continual improvement
  • 38. The Main Elements in HSG65 Organising Planning and Implementing Measuring Performance Policy Reviewing Performance Auditing
  • 39. Management system BS 18004: 2008 Initial Status Review OHS Policy Management Review Planning Checking & corrective action Implementation & operation Continual improvement
  • 40.
  • 41. Reactive to Proactive - Safety Improvement Stages Risk Indicators Time & Effort Safety Culture Regulation Lead Management Lead People Lead
  • 42.
  • 43.
  • 44.
  • 45.
  • 46.
  • 47.
  • 48.
  • 49.
  • 50.
  • 51.
  • 52.
  • 53.
  • 54.
  • 55. Basic steps in risk assessment Classify work activities Identify hazards Determine risk Decide if risk is tolerable Prepare risk control action plan Review adequacy of action plan
  • 56.
  • 57.
  • 58.
  • 59.
  • 60.
  • 61.
  • 62.
  • 63.
  • 64. Risk level Estimator Highly Unlikely Likely Unlikely Harmful Slightly Harmful Extremely Harmful TRIVIAL RISK MODERATE RISK MODERATE RISK MODERATE RISK SUB- STANTIAL RISK INTOLERABLE RISK TOLERABLE RISK TOLERABLE RISK SUB- STANTIAL RISK
  • 65.
  • 66. Risk-based control plan RISK LEVEL ACTION (AND TIMESCALE) TRIVIAL No action, no records TOLERABLE No further action necessary: monitor to ensure controls maintained MODERATE Efforts to reduce risk, but costs of prevention should be limited SUBSTANTIAL Urgent efforts to reduce risk: reduction costs may be high INTOLERABLE Work should not be started or continued until risk reduced: no cost constraints for prevention
  • 67.
  • 68.
  • 69.
  • 70.
  • 71.
  • 72.
  • 73.
  • 74.
  • 75. Risk Matrix Extreme 36 30 24 18 12 6 6 Very high 30 25 20 15 10 5 5 High 24 20 16 12 8 4 4 Low 18 15 12 9 6 3 3 Very low 12 10 8 6 4 2 2 Insignificant 6 5 4 3 2 1 1 Risk levels 6 5 4 3 2 1 Likel ihood Severity
  • 76.
  • 77.
  • 78.  
  • 79.  
  • 80.
  • 81.
  • 82.
  • 83. Steps in advanced risk assessment Cost-Benefit Analysis DEFINE SYSTEM IDENTIFY HAZARDS HAZARDOUS EVENTS HAZARDS EVENTS CONTINUING HAZARDS ANALYSE CONSEQUENCES DECIDE RISK CONTROL STRATEGY VERIFY ESTIMATE/ MEASURE RISKS EVALUATE RISKS NO CHANGE (MONITOR) YES NO IS RISK TOLERABLE? Task-based approach HAZOPS FMEA CHECK-LIST Event Tree Analysis Fault Tree Analysis Event Tree Analysis C Hierarchy Risk Matrix or Risk Calculator 1 in 10 ,000 1 in 1m QRA
  • 84.  
  • 85.  
  • 86.  
  • 87.  
  • 88.
  • 89. Principle of HAZOPS INTENTION DEVIATIONS Possible Causes Potential Consequences
  • 90.
  • 91.
  • 92. NO MORE LESS OTHER THAN GUIDE WORDS Principle of HAZOPS INTENTION DEVIATIONS Possible Causes Potential Consequences Inductive logic Deductive logic
  • 93.
  • 94.
  • 95.
  • 96.
  • 97.
  • 99.
  • 100. Divide system into lines & tanks Local Extract Ventilation Design intention: to provide constant face velocity 5m/sec Fan Filters Face velocity 5 m/sec
  • 101. No Flow Power fails Increased None A Consider emergency concentration power supply
  • 102.  
  • 103. HAZOP WORK-SHEET Storage tank T-1 To store flammable reagent at 1.1 bar and 20° C G UIDE W ORD PROPERTY P OSSIBLE C AUSES C ONSEQUENCES A CTION R EQUIRED MORE LEVEL 1. Pump P-1 fails to stop Reagent released Incorporate high level alarm and trip 2. Reverse from process Reagent released Consider check valve Line 2 LESS 3. Pump P-1 cavitates Damage to P-1 Can reagent explode? If pump overheats? 4. Rupture in Line 2 Reagent released Consider alarm and pump shut-down 5. V-3 open Reagent released Consider alarm 6. V-1 open Same Same 7. Tank rupture Same What external events can cause rupture? NO Same as LESS OTHER THAN COM – 8.Wrong reagent Possible reaction Is reagent sampled before POSITION pumping ? AS WELL AS 9.Impu rity in reagent Possible overpressure, if What are the possible volatile impurities? LESS PRESSURE 10. Break in flare or Reagent released Consider low pressure alarm nitrogen lines 11. Loss of nitrogen Tank implodes What i s design vacuum of tank ? 12. CV-2 fails closed Tank implodes 13. PIC fails Tank implodes MORE 14. PIC fails Reagent released via R.valve What is capacity of CV-1 R. valve? 15. CV-1 fails closed Reagent released via Relief 16. V-7 c losed Same as (15) Is V-7 locked open? 17. Overfill tank See (6) Is V-8 locked open?
  • 104.
  • 105. Steps in advanced risk assessment Cost-Benefit Analysis DEFINE SYSTEM IDENTIFY HAZARDS HAZARDOUS EVENTS HAZARDS EVENTS CONTINUING HAZARDS ANALYSE CONSEQUENCES DECIDE RISK CONTROL STRATEGY VERIFY ESTIMATE/ MEASURE RISKS EVALUATE RISKS NO CHANGE (MONITOR) YES NO IS RISK TOLERABLE? Task-based approach HAZOPS FMEA CHECK-LIST Event Tree Analysis Fault Tree Analysis Event Tree Analysis C Hierarchy Risk Matrix or Risk Calculator 1 in 10 ,000 1 in 1m QRA
  • 106.  
  • 107.
  • 108.
  • 109. Example: Chlorine storage system Pressure switch Storage tank Relay Pump Valve PT
  • 110. Details of pressure switch design Pressure Bellows Micro-switch Pivot Spring Beam PRESSURE SWITCH Pressure switch Storage tank Relay Pump Valve PT
  • 111. Details of the transmitter design: Normally Open relay Pressure switch Storage tank Relay Pump Valve PT
  • 112. FMEA: estimation and evaluation of risks A B C D E I II III IV Probability level Medium Medium risk risk High risk High risk RP1 RP1 RP3 RP3 Low risk Low risk RP2 RP2 Medium Medium risk risk Severity Category A B C D E Probability level 10 -1 10 -2 10 -3 10 -4 10 -5 Description I II III IV Severity category Minor Critical Major Catastrophic Degree Functional failure – minor injury/ ill health No major damage or serious injury Major damage and/or potential serious injury Complete system loss and/or potential fatality Description Probability value Frequent Probable Occasional Remote Improbable
  • 113.  
  • 115. FMEA: summary sheet Rank failure modes according to criticality; Decide actions required to reduce risks; Design measures should be considered as a priority
  • 116. Normally open (NO) cam-activated electrical switch Guard Guard closed closed Guard Guard open open Hazard Hazard
  • 117. Normally closed (NC) cam-activated electrical switch Guard Guard closed closed Guard Guard open open Hazard Hazard
  • 118. Cam operated electrical limit switches
  • 119.
  • 120. Steps in advanced risk assessment Cost-Benefit Analysis DEFINE SYSTEM IDENTIFY HAZARDS HAZARDOUS EVENTS HAZARDS EVENTS CONTINUING HAZARDS ANALYSE CONSEQUENCES DECIDE RISK CONTROL STRATEGY VERIFY ESTIMATE/ MEASURE RISKS EVALUATE RISKS NO CHANGE (MONITOR) YES NO IS RISK TOLERABLE? Task-based approach HAZOPS FMEA CHECK-LIST Event Tree Analysis Fault Tree Analysis Event Tree Analysis C Hierarchy Risk Matrix or Risk Calculator 1 in 10 ,000 1 in 1m QRA
  • 121.
  • 122.  
  • 123. “ FIRE” “ FIRE” Fails Fails Success Major Major Fire A A B B C C D D E E Initiating event Detector Valve Water  supply  Success Success Alarm Major fire Major fire Possible fatalities Possible fatalities Sprinkler might Sprinkler might work work Evacuation of Evacuation of personnel personnel No sprinkler No sprinkler protection protection
  • 124.
  • 125. “ FIRE” “ FIRE” Fails Fails Success P = 0.1 P = 0.1 P = 0.90 P = 0.05 P = 0.05 P = 0.95 P = 0.9 P = 0.1 P = 0.1 P = 0.95 P = 0.05 P = 0.05 P=0.731 Evacuation of Evacuation of personnel personnel No sprinkler No sprinkler protection protection P=0.1 Major fire Possible fatalities Sprinkler might work Major Fire A A B B C C D D E E Initiating Event Detector Valve Water  supply  Success Success Alarm
  • 126.
  • 127. Major fire Possible fatalities Sprinkler might work Major Fire Initiating Event Detector Valve Water  sprinkler  Alarm ƒ = 0.1/yr ƒ = 0.0731 /yr ƒ = 0.01/yr “ FIRE” “ FIRE” Fails Fails Success P = 0.1 P = 0.1 P = 0.90 P = 0.05 P = 0.05 P = 0.95 P = 0.9 P = 0.1 P = 0.1 P = 0.95 P = 0.05 P = 0.05 Evacuation of Evacuation of personnel personnel No sprinkler No sprinkler protection protection A A B B C C D D E E Success Success
  • 128.
  • 129. Steps in advanced risk assessment Cost-Benefit Analysis DEFINE SYSTEM IDENTIFY HAZARDS HAZARDOUS EVENTS HAZARDS EVENTS CONTINUING HAZARDS ANALYSE CONSEQUENCES DECIDE RISK CONTROL STRATEGY VERIFY ESTIMATE/ MEASURE RISKS EVALUATE RISKS NO CHANGE (MONITOR) YES NO IS RISK TOLERABLE? Task-based approach HAZOPS FMEA CHECK-LIST Event Tree Analysis Fault Tree Analysis Event Tree Analysis C Hierarchy Risk Matrix or Risk Calculator 1 in 10 ,000 1 in 1m QRA
  • 130.
  • 131. The ‘OR’ Gate ARRIVE LATE A WAKE UP LATE X DELAYED EN ROUTE Y INCORRECT TIME Z TOP EVENT (OUTPUT) INPUT EVENTS Event ‘A’ occurs if (at least) one of X OR Y OR Z occurs OR
  • 132. The ‘AND’ Gate Event ‘A’ occurs if both X AND Y occur
  • 133. FTA –lighting system Fuse Switch Bulb 1 Bulb 2 Power Source Room dark Power off Power supply failed Switch open Fuse Blown Both bulbs burned out Bulb 1 burned out Bulb 2 burned out
  • 134. Risk Assessment Methodologies Human Reliability Analysis (HRA) Richard Booth
  • 135. Machine/ P rocess CONTROLS Display H UMAN- M ACHINE I NTERFACE
  • 137. Human Error as a function of stress level Error Rate Stress Level Bored Over-excited
  • 138. Hierarchical Task Analysis ‘HTA’ A process of developing a description of a task in terms of operations - things which people should do and plans - statements of conditions when each task/step has to be carried out
  • 139.
  • 140.
  • 141.  
  • 142.  
  • 143. Hierarchical Task Analysis ‘HTA’ 0 WIRE A THREE PIN PLUG 1 PREPARE PLUG 2 PREPARE CABLE 3 4 TEST PLUG 2.1 CUT & STRIP OUTER CABLE SHEATH 2.2 2.3 CARRY OUT ASSEMBLY 3.2 3.3 3.4 SELECT AND FIT 13 Amp FUSE 3.5 TIGHTEN CABLE STRIP & REPLACE COVER Plan 0: do in order Plan 2: 1 then 2 then 3 Plan 3: 1,2,3,4 then 5 CUT & STRIP INDIVIDUAL WIRES AS MARKED TERMINATE ALL 3 WIRE STRANDS 3.1 FIT BLUE WIRE IN TERMINAL 1 & TIGHTEN SCREW FIT YELLOW WIRE IN TERMINAL 2 & TIGHTEN SCREW FIT BROWN WIRE IN TERMINAL 3 & TIGHTEN SCREW
  • 144.  
  • 146.
  • 147.
  • 148.
  • 149. HSE ‘ALARP’ Intolerable Risk Upper Limit Lower Limit Negligible As Low As Reasonably Practicable ‘ALARP’ Broadly acceptable
  • 150. HSE ‘ALARP’ Intolerable Risk Upper Limit: 1 in 1,000 (workers) 1 in 10,000 (public) Risk of death / year Lower Limit: 1 in a million (workers & public) Risk of death / year Negligible As Low As Reasonable Practicable ‘ALARP’ Broadly acceptable
  • 151.
  • 152.
  • 153. Death as an annual experience Cause of Death chance/year All causes Overall average 55-64 men women 35-44 men women 5-14 boys girls Hang gliding Road accidents Gas explosion (home) Electrocution (home) Lightning 1 in 87 1 in 65 1 in 110 1 in 578 1 in 873 1 in 4,400 1 in 6,250 1 in 670 1 in 10,200 1 in 1 million 1 in 1 million 1 in 10 million
  • 154. Death as an annual experience Cause of Death chance/year Work Accidents deep sea fishing extraction oil / gas construction agriculture all manufacturing 1 in 750 1 in 990 1 in 10,200 1 in 13,500 1 in 53,000
  • 155. Death as a consequence of an activity Activity Chance of death Travel for 100,000 km by motor bike by pedal cycle by car by rail by bus by air Balloon (Atlantic) Pregnancy Anaesthesia 1 in 100 1 in 200 1 in 2,200 1 in 9,000 1 in 22,000 1 in 44,000 1 in 3 1 in 13,000 1 in 25,000
  • 156. Average loss of life expectancy as a consequence of an activity Cause Loss of Life Expectancy (days) Being unmarried (male) Smoker (male) Being unmarried (female) Smoker (female) Dangerous job Vehicle accidents Homicide Average job Medical X rays Coffee drinking Reactor accidents Nuclear industry Smoke alarm Mobile coronary-care units 3,500 2,250 1,600 800 300 207 90 74 6 6 0.2 to 2 0.2 -10 -125
  • 157.
  • 158. Cost-benefit model Cost £ Number of accidents Cost prevention - Employer Cost accidents - Employer Total Costs - Employer ‘ Optimum’ performance - Employer
  • 159.
  • 160.
  • 162.
  • 163.
  • 164.
  • 165.
  • 166.
  • 167.
  • 168.
  • 169.
  • 170.
  • 171.
  • 172. League Women voters College students Active club members Experts Nuclear power 1 1 8 20 Motor vehicles 2 5 3 1 Handguns 3 2 1 4 Smoking 4 3 4 2 Motorcycles 5 6 2 6 Alcoholic drinks 6 7 5 3 Private aviation 7 15 11 12 Police work 8 8 7 17 Pesticides 9 4 15 8 Surgery 10 11 9 5 Firefighting 11 10 6 18 Large construction 12 14 13 13 Hunting 13 18 10 23 Spray cans 14 13 23 26 Mountain climbing 15 22 12 29 Bicycles 16 24 14 15 Commercial aviation 17 16 18 16 Electricity (non-nuclr) 18 19 19 9 Swimming 19 30 17 10 Contraceptives 20 9 22 11 Skiing 21 25 16 30 X-rays 22 17 24 7 Football 23 26 21 27 Railroads 24 23 20 19 Food preservatives 25 12 28 14 Food colouring 26 20 30 21 Power mowers 27 28 25 28 Antibiotics 28 21 26 24 Home appliances 29 27 27 22 Vaccinations 30 29 29 25
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  • 189. Change Analysis: fall in Victoria Square No recognition of changed circumstances /route Walking/observing on ‘autopilot’ Walking/observing on ‘autopilot’ Attention directed to stall produce Market stalls a significant distraction No unusual ‘distractions’ Also, carrying a shoulder bag and rucksack Pedestrians difficult to navigate around Pedestrians few and no effort to navigate around Diversion necessary from normal route (one step to descend) Frankfurt ‘Christmas’ Market in operation No physical barriers for normal route (and no steps) Anxiety about Course Stress state ‘elevated’ Stress state ‘normal’ Result of dealing with arrangements for AI Course at last minute More preoccupied than usual when going to catch (the) train Preoccupied when going to catch a train Indicates that IP (me) was not walking unduly fast, as was the case Time to get to station 35m Time to get to station 30m Comments Accident situation Normal Situation
  • 190. Change Analysis: fall in Victoria Square - consequences Emergency admission to hospital suffering from whiplash injuries three days later Fall on unseen step, and arrival at station bloody and shaken Delegates at AI course impressed by this Change Analysis! Safe arrival at station Situational violation (need to catch the train) Cancelled ambulance despite police advice (and not given necessary treatment) Accept full first aid treatment Comments Accident situation Normal Situation
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  • 197. Accident Scene Warehouse X Racking Victim FLT Offices
  • 198. Fatality due to FLT collision & FLT Collides with person & Victim Dies Person in the FLT Path FLT Fails to Stop Not aware of Need to Stop Aware but unable to Stop Driver actually Ill Driving Too fast Faulty Brakes Not Aware of Person Thinks person will evade 1 Person Aware of FLT Unaware of FLT Thinks FLT will Evade Unable to move out of way Person actually Ill Person Slips/trip Falls Disabled Time too short & Person Did Not See FLT Person Did Not Hear FLT 2 3 Poor visibility Vision obstructed Not looking Reversing Person Conspicuity Poor visibility Vision obstructed Not looking visually impaired FLT Conspicuity Wearing PPE Noisy place FLT quiet Wearing stereo Hearing impaired FLT Accident Investigation
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  • 200. Events and Casual Factors General Format Systemic Factors Contributing Factors Systemic factors Contributing factors Secondary events Primary events
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Notas do Editor

  1. ACCIDENT Investigate accident - process and outcome steered by the preconceptions of the investigator about accident causation Attribute primary cause to shortco mings in the behaviour of the injured person (unsafe acts) Devise a RULE forbidding the recurrence of the unsafe acts Attribute primary cause to shortcomings in the physical environment (unsafe conditions) Devise a TECHNICAL solution to make the conditions safe
  2. Notes
  3. The International Nuclear Safety Advisory Group (IAEA 1991) has defined safety culture: “ Safety culture is that assembly of characteristics and attitudes in organisations and individuals which establishes that, as an overriding priority, nuclear plant safety issues receive the attention warranted by their significance.” They suggest that “the definition relates Safety Culture to personal attitudes and habits of thought and to the style of organizations.” They go on to say: “ A second proposition then follows, namely that such matters are generally intangible ; that nevertheless such qualities lead to tangible manifestations ; and that a principal requirement is the development of means to use the tangible manifestation to test what is underlying .” my italics] INTERNATIONAL NUCLEAR SAFETY ADVISORY GROUP. Safety culture. Safety Series , 1991, 75-INSAG-4 (IAEA, Vienna)
  4. Notes More detailed information about the key requirements of the Regulations is given in the Resource Materials starting at page RM4.
  5. Notes More detailed information about the key requirements of these Regulations is given in the Resource Materials starting at page RM7.
  6. Notes More detailed information about the key requirements of these Regulations is given in the Resource Materials starting at page RM7.