Safety Accident Investigation and Resolution Procedure

First, the accident investigation step

1. Notification of the accident

2. Set up an accident investigation team

3. On-site treatment of the accident

4. Collection of physical evidence

5. Collection of accident facts

6. Collecting witness materials

7. Live Photography

8. Accident diagram drawing

9. Analysis of the cause of the accident

10. Preparation of accident investigation report

11. The accident investigation is filed.

Second, the contents of the accident investigation report

1. Background information

( 1 ) Basic situation of the accident unit

( 2 ) When and where the accident occurred

( 3 ) Persons and other situations involved in the accident

( 4 ) Staff and Casualty Accident Registration Form

( 5 ) Operators and witnesses

( 6 ) Emergency rescue situation

2. Accident description

( 1 ) The sequence of accidents

( 2 ) The degree of damage

( 3 ) Casualties and economic losses

( 4 ) The type of accident

( 5 ) The nature of the accident

( 6 ) Loads or energy (energy or harmful substances).

3. The cause of the accident

( 1 ) Direct cause (energy source)

( 2 ) Indirect causes (unsafe behavior of people and unsafe status of things).

4. Accident lessons and suggestions for preventing accidents ( including immediate measures and long-term action plans )

5. Deal with the person responsible for the accident

6. List of members of the accident investigation team

7. Other matters needing explanation

III. Commonly used techniques and methods for accident investigation

1. Fault Tree Analysis Method ( FTA )

2. Failure Type and Impact Analysis Method (FMEA)

3. Change analysis method (similar to "Danger and operability study") Look for things that deviate from the standards and specifications, and investigate all problems caused by unintended changes.

(1) Determine the problem, that is, what happened

(2) Establishment of related standards and specifications

(3) Identify what changes have been made, where they have been changed, and the description of the changes; that is, what changes have occurred, where the changes occurred, when and how

(4) Description of factors affecting change and description of factors that do not affect change

(5) Identify the characteristics, characteristics and specific conditions of the changes

(6) Make a detailed list of possible causes of changes

(7) Select the most likely reason for the change (8) Find out the preventive measures against the risk factors associated with the change.

IV. General principles for accident investigation and evidence collection

Seek truth from facts, objective truth, completeness and completeness.

V. Accident related physical evidence collection

1. Collect on-site physical evidence, including the location of broken parts, debris, residues, and hazards;

2. Label all items collected, indicating the location, time, and manager;

3. All items should be kept as they are, no flushing is allowed;

4. Items that are hazardous to health should be protected by safety measures that do not damage the original evidence;

6. Collection of accident facts

1. Materials related to accident identification and recording

(1) The unit, place and time of the accident;

(2) The names, genders, ages, education levels, occupations, technical levels, length of service, length of service, and wages paid for victims and perpetrators;

(3) The technical status of the victims and the perpetrators, and the status of receiving safety education;

(4) At what time does the victim and the perpetrator start the work, the content of the work, the workload, the operating procedures, the actions (or location) at the time of the accident;

(5) Past accident records of victims and offenders.

2. The facts related to the accident

(1) The performance and quality of the equipment and facilities before the accident;

(2) Materials used, if necessary, physical or chemical performance tests and analysis;

(3) Information and implementation of technical documents, work instructions and rules and regulations related to design and technology;

(4) The status of the work environment, including lighting, humidity, temperature, ventilation, sound, color, roads, work surface conditions, and sampling and analysis of toxic and hazardous substances in the work environment;

(5 ) The status of personal protection measures should pay attention to its effectiveness, quality, and scope of use;

(6) The health status of the victims and perpetrators prior to the accident;

(7) Other details or factors that may be related to the cause of the accident.

Seven, the basic steps of the accident analysis

(1) Organize and read investigation materials

(2) analysis of injury methods: the total number of injuries; the nature of the injury; the cause of things; harm; damage; unsafe conditions; unsafe behavior.

(3) Determine the direct cause of the accident. Considered from two aspects: energy sources and hazardous materials.

(4) Determine the indirect cause of the accident, considering from two aspects : human unsafe behavior and unsafe status of the material.

VIII. Analysis of the direct cause of the accident

1 . Mechanical, material or environmental insecurity

(1) Protection, insurance, signal and other devices are lacking or defective

1) No protection. Including : no protective cover; no safety device; no alarm device; no safety mark; no guardrail or guardrail damaged; ( electrical ) ungrounded; poor insulation; local ventilator without silencing system, high noise; dangerous house operation; not installed Prevent the "sports car" block or guardrail; other.

2) Improper protection. Including : protective cover is not in place; protective device is improperly adjusted; tunnel excavation and tunnels are not properly supported; improper explosion-proof devices; insufficient safety distances for cutting and stacking operations; concealing all defects in blasting operations; exposed live parts of electrical devices;

(2) Defective equipment, facilities, tools, and accessories

1) The design is improper and the structure does not meet the safety requirements. Including : the access door to block the line of sight; brake device is lacking; safety spacing is not enough; block the car network is missing; workpiece has sharp burrs, burrs; facilities have sharp chaos; other.

2) Insufficient strength. Including : The mechanical strength is not enough; The insulation strength is not enough; The rope that lifts the weight does not meet the safety requirement; Others.

3) The equipment is operating in an abnormal state. Including : equipment with "disease" operation; overloaded operation; other.

4) Maintenance and adjustment are bad. Including : equipment is in disrepair; ground is uneven; improper maintenance, equipment failure; other.

(3) PPE appliances - protective clothing, gloves, goggles and masks, respirators official supporter, hearing protectors, seat belts, safety helmets, safety shoes missing or defective

1) No personal protective equipment and appliances.

2) The protective equipment and appliances used do not meet the safety requirements.

(4) Poor environment of production ( construction ) site

1) Bad lighting. Including : Insufficient illumination; dust on the job site is unclear; light is too strong.

2) Poor ventilation. Including : no ventilation; low efficiency of the ventilation system; air flow short circuit; shot blasting when the power is stopped and stopped; gas emission does not reach the safe concentration of blasting operations; gas exceeds the limit; other.

3) The workplace is narrow.

4) The workplace is cluttered. Including : tools, products, materials stacked unsafe; at the time of harvest, did not open the "safe road"; welcome the tree, sit temple trees, hanging trees without treatment; other.

5) The configuration of traffic lines is not safe.

6) Operational procedures are not designed or configured.

7) The ground is slippery. Including : oil or other liquids on the ground; ice and snow cover; other slippery materials on the ground.

8) The storage method is not safe.

9) Improper ambient temperature and humidity.

2 . Human unsafe behavior

(1) Operation error, neglect of safety, neglect of warning

1) Start, shut down or move the machine without permission.

2) No signal is given when the starter is turned on or off.

3) The switch is not locked, causing accidental rotation, energization or leakage.

4) Forgot to turn off the device.

5) Ignore warning signs and warning signals.

6) Operation error ( refers to the operation of buttons, valves, wrenches, handles, etc. ) .

7) Run homework.

8) The feeding or feeding speed is too fast.

9) Mechanical overspeed.

10) Driving a motor vehicle illegally.

11) Drinking work.

12) Passenger and cargo mixed.

13) When the press is in operation, the hand reaches into the stamping die.

14) The workpiece is not fastened tightly.

15) Blow the iron scraps with compressed air.

16) Others.

(2) Failure of the safety device

1) The safety device was removed.

2) The safety device is clogged and lost its function.

3) The adjustment error causes the safety device to fail.

4) Others.

(3) Use of unsafe equipment

1) Temporary use of weak facilities.

2) Use equipment without safety devices.

3) Others.

(4) Hand instead of tool operation

1) Use hand instead of hand tools .

2) Remove the chips by hand.

3) Fix the workpiece without using a jig and perform machining with the workpiece.

(5) Improper storage of objects ( finished products, semi-finished products, materials, tools, swarf, production supplies, etc. )

(6) Adventure into dangerous places

1) Adventure into the culvert.

2) Close to leakage ( no safety facilities ) .

3) When cutting, collecting materials, transporting materials and loading vehicles, they have not left the danger zone.

4) Without permission of safety inspection personnel to enter the tank or well.

5) Did not "knock out the top" to start work.

6) Advance signal.

7) The marshalling yard speeds up and down.

8) Open fire in flammable and explosive places.

9) Take a mine car privately.

10) Walk in the winding lane.

11) Did not look up in time.

(7) Climb and sit in an unsafe position ( such as platform guardrail, car baffle, crane hook )

(8) Working under suspension and staying

(9) Refueling, repair, inspection, adjustment, welding, cleaning, etc. during operation of the machine

(10) Distracting behavior

(11) Disregard its use in operations or occasions where personal protective equipment must be used

1) Did not wear goggles or masks.

2) Did not wear protective gloves.

3) Did not wear safety shoes.

4) Did not wear a safety helmet.

5) No breathing aids are worn.

6) No seat belt is worn.

7) Did not wear a work cap.

8) Others.

(12) Insecure clothing

1) Work through fat garments next to equipment with rotating parts.

2) Wear gloves when handling equipment with rotating parts.

3) Others.

(13) Handling of dangerous materials such as flammable, explosive, etc.

IX. Analysis of indirect causes of accidents

1. There are defects in technology and design - there are problems in the design, construction and material use of industrial components, buildings, mechanical equipment, instrumentation, process, operation methods, maintenance inspections, etc.

2. Insufficient education and training, no training, lack of knowledge of safe operation techniques.

3. The labor organization is irrational.

4. There is a lack of inspection or guidance of on-site work.

5. There is no safe operation procedure or is not sound.

6. No or no serious accident prevention measures are implemented; failure to rectify hidden accidents is not effective.

7. Others.