Environmental Engineering Reference
In-Depth Information
Findings.included
•.
The.regular.electrician.was.sick.so.a.substitute.who.was.not.trained.on.
high.voltage.was.used.(Cause.Code.5A,.No.Training.Provided).
•.
The. substitute. did. not. follow. procedures.. The. substitute. tied. out. the.
interlocks. and. used. the. wrong. meter. (Cause. Code. 3C,. Violation. of.
Requirement.or.Procedure).
•.
The.fuse.obtained.from.the.storeroom.was.outdated.and.was.no.good.
(Cause.Code.1A,.Defective.or.Failed.Part).
•.
The.large.fan.was.not.designed.for.cycling.(frequent.startups).and.had.been.
regularly.blowing.fuses.(Cause.Code.4B,.Inadequate.or.Defective.Design).
•.
The. supervisor. knew. the. substitute. was. inexperienced. but. did. not.
observe.the.substitute.or.give.any.special.assistance.(Cause.Code.6C,.
Inadequate.Supervision).
•.
Known. defects. had. not. been. corrected. (Cause. Code. 6A,. Inadequate.
Administrative.Control).
To.correct.these.conditions,.the.following.recommendations.were.made:
•.
Investigate.and.repair.the.system.so.that.it.does.not.blow.fuses.
•.
Train.supervisors.to.ensure.that.the.worker.is.qualiied.for.that.task.
•.
Provide.high-voltage.training.as.needed.
•.
Evaluate. management. response. to. safety. problems. and. operation. of.
malfunctioning.equipment.
As.a.result.of.the.potential.signiicance.of.this.occurrence,.a.formal,.detailed.root.
cause.analysis.was.performed..A.high.level.of.effort.was.expended.but.the.effort.
was.justiied.due.to.the.consequences.of.a.repeat.occurrence.
When.preparing.to.develop.a.Causal.Factor.Analysis.chain.as.stated.earlier,.begin.
by. collecting. all. possible. facts. as. soon. as. possible.. It. will. not. be. possible. to. collect.
the. Events,. Conditions,. etc.. chronologically,. so. investigators. will. need. to. revisit. the.
chain.over.and.over.again.and.place.them.in.order..When.it.is.seen.that.something.is.
missing.or.does.not.make.sense,.the.need.to.reinvestigate.that.area.and.make.sense.
of. it. should. be. undertaken.. It. is. a. good. idea. to. use. a. charting. method. that. can. be.
edited.easily,.in.order.to.inish.the.chart.appropriately..For.instance,.use.magnets.on.a.
metal.background.or.“Post-It-Notes”.on.a.large.piece.of.paper,.and.the.Events.and/or.
Conditions.can.be.easily.moved.without.any.or.little.confusion.when.new.facts.arise..
If.a.chart.is.being.drawn,.then.every.time.a.new.fact.arises,.drawing.up.a.new.chart.
creates.confusion.and.messy.work..This.would.also.be.very.time.consuming.and.not.
very.cost.effective.
As.stated.earlier,.a.Causal.Factor.Chain.is.used.to.trace.the.sequence.of.events.
surrounding.an.accident,.including.the.Conditions.that.exist.for.the.accident.to.occur..
First,.an.examination.of.the.event.immediately.preceding.the.accident.should.be.per-
formed.to.determine.if.it.is.the.signiicant.event..To.evaluate.the.signiicance.of.the.
event,.ask.the.following.question:.“If.this.event.had.not.occurred,.would.the.accident.
Search WWH ::




Custom Search