LOSS PREVENTION

Investigation of Accidents and Hazardous Events

Will accidents occur because we do not know or do not have the means to prevent them? In fact, accidents occur partly due to the inherent imperfections of the system (equipment, facilities, procedures and the man himself), but largely the accidents occur because we do not use the available knowledge. The acidents occur when we no longer control or eliminate the hazards, which often have been already identified.

A hazard not eliminated or not controlled or a system failure can result an undesirable event. This undesirable event can cause adverse consequences. Thus, we can define accident as any undesirable event that can cause adverse consequences to people, property, environment and operation continuity.

We spend a lot of time and money acquiring new knowledge and presenting the results in conferences, publications, etc. However, we spend much less effort answering the questions: “How can we persuade people to use the knowledge already available?”; “How can we convince people to use the new knowledge that we are giving to them, when they are not even using the knowledge they already have?” According to Trevor Kletz, “Companies do not have memory and the incidents occur again”.

Generally, serious accidents are not completely strange, isolated and unprecedented events. When a serious accident occurs, it is very probable that some or all of their previous contributions (or causes) have been repeated in the past; but, fortunately, this serious event has not become reality due to some employee’s action or some specific condition.

Several studies show that for each major accident with significant proportions, many other minor accidents occur and an even larger number of what we call “near misses”.

According to researchers Tye & Pearson, H.S.E., 1991, the frequency distribution as a function of severity is approximately the following: for each catastrophic accident, one have 3 critical accidents, 50 moderate accidents, 80 marginal accidents and 400 accidents that may be classified as “near misses”. Characterizing these categories, one can say that:

We need to encourage all company’s employees to report any event to their supervisors, so they can evaluate whether a major accident involving large losses could have occurred. Ideally, “near misses” should be investigated and reported as if a serious accident had taken place indeed.

The most important requirement to encourage incident reports is a company with a blame-free culture. The involved employees should never feel there will be recriminations with regard to what is reported, even if initially seems they had made a mistake.