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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. 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

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  1. MODERN METHOD ON ACCIDENT INVESTIGATION V.P.GHOLAP V.LAKSHMAN S.BHATTACHARYA P.K.GHOSH AERB

  2. ASSET • ASSESSMENT OF SAFETY SIGNIFICANT EVENTS TEAM • DEVISED BY IAEA - • PREVENTION OF INCIDENTS - NPPS • ENSURE CONSISTENCY AND COMPREHENSIVENESS OF THE REVIEW OF INCIDENT INVESTIGATIONS

  3. 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)

  4. ASSET METHODOLOGY • SELECTION OF OCCURRENCES • IDENTIFICATION OF DIRECT CAUSE • IDENTIFICATION OF ROOT CAUSE • DETERMINATION OF CORRECTIVE ACTIONS • GENERIC LESSONS

  5. ASSET METHODOLOGY -1 • SELECTION OF OCCURRENCES • ELEMENT THAT FAILED TO PERFORM AS EXPECTED- TO BE IDENTIFIED

  6. ASSET METHODOLOGY-2 • IDENTIFICATION OF DIRECT CAUSE • LATENT WEAKNESS OF PERSONNEL, EQUIPMENT OR PROCEDURE

  7. ASSET METHODOLOGY -3 • IDENTIFICATION OF ROOT CAUSE • DEFICIENCY IN DETECTION OF ERROR AND RESTORATION OF ROOT CAUSE

  8. ASSET METHODOLOGY-4 • DETERMINATION OF CORRECTIVE ACTIONS • GENERIC LESSONS

  9. INVESTIGATION STEPS • NARRATION OF EVENT • BUILD CHRONOLOGICAL SEQUENCE • BUILD LOGIC TREE • IDENTIFY NATURE OF OCCURRENCES (EQUIPMENT, PROCEDURE OR PERSONNEL)

  10. INVESTIGATION STEPS..contd. • IDENTIFY DIRECT CAUSE • IDENTIFY ROOT CAUSE • DETERMINE CORRECTIVE ACTIONS FOR EACH OCCURRENCE • ACTION PLAN FOR REMEDY

  11. 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.

  12. 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.

  13. Case Study- Fatal Accident at Kaiga 3&4

  14. Case Study- Fatal Accident at Kaiga 3&4

  15. Case StudyFatal Accident at Kaiga 3&4

  16. 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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