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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

slide2
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.

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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