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MODERN METHOD ON ACCIDENT INVESTIGATION. V.P.GHOLAP V.LAKSHMAN S.BHATTACHARYA P.K.GHOSH AERB. ASSET. A SSESSMENT OF S AFETY S IGNIFICANT E VENTS T EAM DEVISED BY IAEA - PREVENTION OF INCIDENTS - NPPS ENSURE CONSISTENCY AND COMPREHENSIVENESS OF THE REVIEW OF INCIDENT INVESTIGATIONS.

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Modern method on accident investigation

MODERN METHOD ON ACCIDENT INVESTIGATION

V.P.GHOLAP

V.LAKSHMAN

S.BHATTACHARYA

P.K.GHOSH

AERB


ASSET

  • ASSESSMENT OF SAFETY SIGNIFICANT EVENTS TEAM

  • DEVISED BY IAEA -

  • PREVENTION OF INCIDENTS - NPPS

  • ENSURE CONSISTENCY AND COMPREHENSIVENESS OF THE REVIEW OF INCIDENT INVESTIGATIONS


Asset approach philosopy
ASSET APPROACH-PHILOSOPY

  • EVENTS – Occur - because of

  • FAILURE - to perform as expected- due to

  • LATENT WEAKNESS - not timely

    eliminated - (direct cause)

  • DEFICIENCIES OF PLANT SURVEILLANCE PROGRAMME - on equipment, personnel and procedures

    (root cause)


Asset methodology
ASSET METHODOLOGY

  • SELECTION OF OCCURRENCES

  • IDENTIFICATION OF DIRECT CAUSE

  • IDENTIFICATION OF ROOT CAUSE

  • DETERMINATION OF CORRECTIVE ACTIONS

  • GENERIC LESSONS


Asset methodology 1
ASSET METHODOLOGY -1

  • SELECTION OF OCCURRENCES

    • ELEMENT THAT FAILED TO PERFORM AS EXPECTED- TO BE IDENTIFIED


Asset methodology 2
ASSET METHODOLOGY-2

  • IDENTIFICATION OF DIRECT CAUSE

    • LATENT WEAKNESS OF PERSONNEL, EQUIPMENT OR PROCEDURE


Asset methodology 3
ASSET METHODOLOGY -3

  • IDENTIFICATION OF ROOT CAUSE

    • DEFICIENCY IN DETECTION OF ERROR AND RESTORATION OF ROOT CAUSE


Asset methodology 4
ASSET METHODOLOGY-4

  • DETERMINATION OF CORRECTIVE ACTIONS

  • GENERIC LESSONS


Investigation steps
INVESTIGATION STEPS

  • NARRATION OF EVENT

  • BUILD CHRONOLOGICAL SEQUENCE

  • BUILD LOGIC TREE

  • IDENTIFY NATURE OF OCCURRENCES (EQUIPMENT, PROCEDURE OR PERSONNEL)


Investigation steps contd
INVESTIGATION STEPS..contd.

  • IDENTIFY DIRECT CAUSE

  • IDENTIFY ROOT CAUSE

  • DETERMINE CORRECTIVE ACTIONS FOR EACH OCCURRENCE

  • ACTION PLAN FOR REMEDY


Case study fatal accident at kaiga 3 4
Case Study- Fatal Accident at Kaiga 3&4

  • Occurrence Narrative:

    1 Gopal Biswas- electrocuted and succumbed to injury while working with portable power saw for cutting wooden runner batten.

    2 The job started in an open area in -at 1530 hrs when electrical connection was established for power-saw without the sub distribution board ELCB.

    3 Before 1720 hrs, rain started and Shri Biswas left the power saw in open in the rain and returned when rain stopped.

    4 As soon as he switched on the power saw and held it by hand he received electric shock.

    5 He was shifted to hospital where he was declared dead.


Case study fatal accident at kaiga 3 41
Case Study- Fatal Accident at Kaiga 3&4

  • Chronological Sequence:

    1530 hrs work started

    1700 hrs- rain started

    1720 hrs – rain stopped

    1720 hrs – portable saw was switched on and the user suffered electrocution

    1730 hrs operator was taken to hospital declared and dead.


Case study fatal accident at kaiga 3 42
Case Study- Fatal Accident at Kaiga 3&4


Case study fatal accident at kaiga 3 43
Case Study- Fatal Accident at Kaiga 3&4


Case study fatal accident at kaiga 3 44
Case StudyFatal Accident at Kaiga 3&4


Applicability
APPLICABILITY

  • APPLICABLE TO ANY INDUSTRIAL ACTIVITY WHERE THE INDUSTRY’S MANAGEMENT OR THE RELEVANT REGULATORY BODY WANT TO PREVENT ACCIDENTS AND INCIDENTS.

  • APPLICABLE AS A TOOL OF MANAGEMENT TO HAVE PRACTICAL DAILY CONTROL OF EVENTS AND PREVENTION OF SIGNIFICANT SAFETY RELATED EVENTS.


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