Industrial Accident Systemic Investigation Techniques

Investigating and reporting of unplanned events such as accidents, incidents, and even near-miss events are critical for identifying and controlling potential safety risks. The purpose of these activities is not to find fault or lay blame, but rather to identify the basic causes of accidents and incidents so that controls can be put in place to prevent further occurrences. Hence it is essential to look beyond the immediate cause of an accident and look for the contributing factors and basic causes.By now, the lack of effective accident investigation methodology and the competency level of the safety professionals responsible for accident investigation remain to be one of the key factors hindering the prevention of occupational injuries and process accidents. Hence the primary objective of this study is to provide practical solutions to the problems commonly encountered in incident investigation in China.In this thesis, the advantages, disadvantages and applicaiton scope of several accident investigation methods are analysised, which are commonly applied both at home and abroad at preaent and include Barrier Analysis,Change Analysis,Events and Causal Factors Charting, Sequentially Timed Events Plotting, TRIPOD Theory, Systematic Causal Analysis Technique, Fault Tree Anaslysis, Management Oversight and Risk Tree, Event Tree Analysis, Why Tree Analysis, Causal Tree Analysis, Work Accidents Investigation Technique, etc. Based on the analysis and the accident investigation procedures suggested by I.S.Sutton, a systematic approach for accident investigation is proposed in this study through modifying ECFC and root cause analysis. The methodology is primarily composed of six steps which are initial investigation, founding investigation team, developming sequentially time plotting, root cause analysis and deliverying final report&recommendation.At last, the methodology is applied to investigate an explosion accident of launcher pig in a gas plant and the reasonable direct causes, indirect causes&root causes are found. Therefore, the methodology is proved to be practicable for accident investigation.