Accident investigation - 209 entries found

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2011

CIS 12-0098 Learning the lessons - How to respond to deaths at work and other serious incidents
This guide aims to help organizations respond to hazardous events such as accidents, work-related violence and other dangerous occurrences. Contents: need for internal investigations; preparing and planning the response to hazardous events; initial response; internal investigations; competent investigators; how to avoid common failings in investigations; good practice in investigation reporting.
Institution of Occupational Safety and Health, The Grange, Highfield Drive, Wigston, Leicestershire, LE18 1NN, United Kingdom, Feb. 2011. 21p. Illus. Bibl.ref.
Learning_the_lessons_[INTERNET_FREE_ACCESS] [in English]

CIS 11-0704 Schröder-Hinrichs J.U., Baldauf M., Ghirxi KT.
Accident investigation reporting deficiencies related to organizational factors in machinery space fires and explosions
This article presents a review of 41 accident investigation reports related to ship engine-room space fires and explosions. The objective was to find out whether organizational factors were identified during maritime accident investigations. An adapted version of the Human Factor Analysis and Classification System (HFACS) with minor modifications related to engine room features was applied. Findings show that organizational factors were not identified by maritime accident investigators to the extent expected, had the IMO guidelines been observed. Instead, contributing factors at the lower end of organizational echelons are over-represented. Implications of these findings are discussed.
Accident Analysis and Prevention, May 2011, Vol.43, No.3, p.1187-1196. Illus. 44 ref.

CIS 11-0703 Camino López M.A., Fontaneda I., González Alcántara O.J., Ritzel D.O.
The special severity of occupational accidents in the afternoon: "The lunch effect"
This study analyzed data from over 10 million occupational accidents having occurred in Spain between 1990 and 2002, with emphasis on the severity of occupational accidents suffered by construction workers at different hours of the day. It was observed that during the interval of time from 13:00 h to 17:00 h, the rates of severe and fatal accidents were particularly high. The opinions of workers concerning the possible reasons for these accidents were obtained by means of questionnaires administered by occupational physicians during periodical health check-ups. This higher accident rate is termed the "lunch effect", and is attributed to several potential risk factors for occupational accidents around lunchtime in Spain, including alcohol consumption.
Accident Analysis and Prevention, May 2011, Vol.43, No.3, p.1104-1116. Illus. 35 ref.

CIS 11-0553 Lessons to be learned from electrical accidents
Les leçons à tirer des accidents électriques [in French]
This article presents the findings of a Health and Safety Executive Report according to which 40% of fatal occupational accidents in the United Kingdom implicate electricity. The report is based on the analysis of accidents reported between 1996 and 2008. The article next proposes seven "golden rules" for working safely in the presence of electrical equipment. It also includes boxes containing short electrical accident descriptions together with the lessons to be learned, with reference to the "golden rules".
Prevent Focus, May 2011, p.12-15. Illus.

2010

CIS 12-0019 Guide for analysis - Occupational accidents
Guia de análise - Acidentes do trabalho [in Portuguese]
Accident analyses carried out by enterprises in Brazil too often limit themselves to simply pointing fingers or hastily assigning human error to the victims or their fellow workers. This guide explains how to analyze accidents and adverse events in order to better understand the underlying causes and make honest appraisals of true responsibilities. It presents a four-step approach: data collection; analysis of the information; identification of means of control; action plan.
Ministério do trabalho e emprego, Secretaria de inspeção do trabalho, Departamento de segurança e saúde no trabalho, Vera Lúcia Ribeiro de Albuquerque, Esplanada dos Ministérios Bl. F, Anexo - Ala B, 1º Andar-Sala 176, 70059-900 Brasília, Brazil, 2010. 75p. Illus. 42 ref.
Guia_de_análise_Acidentes_do_trabalho_[INTERNET_FREE_ACCESS] [in Portuguese]

CIS 11-0707 Akdur O., Ozkan S., Durukan P., Avsarogullari L., Koyuncu M., Ikizceli I.
Machine-related farm injuries in Turkey
Traumas connected with agricultural production can result in serious injuries and mortality. The objective of this study was to describe the characteristics of agricultural machinery-related work injury cases admitted to hospital emergency departments of a region of Turkey, and to assess factors related to injury severity and hospital admission. All the cases presented related to injuries caused by work with agricultural machines between January 2006 and November 2007 were included in the study. Information was collected concerning the demographic structures of the patients. Injury sites, injury types, and clinical features were recorded. Initial injury severity scores of all the cases were diagnosed at hospital admission. The most common injuries were tractors (46% of cases), and all of these were fall traumas; 18.9% of the cases was considered slight injuries, 43.2% moderate, 37.9% severe. Two cases resulted in fatality. Findings suggest that tractors are the most dangerous agricultural machines, and falls from tractors as the most common injury mechanism among machine-related injuries, especially for young people.
AAEM - Annals of Agricultural and Environmental Medicine, 2010, Vol.17, p.59-63. Illus. 25 ref.
Machine-related_farm_injuries.pdf [in English]

CIS 11-0621 Varakina Z.L., Vyazmin A.M., Sannikov A.L., Nygard C.H., Grjibovski A.M.
Fatal occupational injuries in the Arkhangelsk region, Northwest Russia
The Arkhangelsk region is among the areas with the highest burden of fatal occupational injuries (FOI) in Russia. Data on all FOI reported in the Arkhangelsk region in 1996-2007 were obtained from the State Labour Inspection. Data on the number of employees were collected at the Regional Federal State Statistics Service. The incidence of FOI was calculated by gender, age and economic activity per 100,000 employees. Blood alcohol concentration for all victims was available from the autopsy records. Altogether, there were 734 occupational fatalities during the study period, 94% of them were among men. The incidence of FOI decreased from 18.6 in 1996 to 11.7 in 2007 among men and from 1.3 in 1996 to 0.3 in 2006 among women. The agriculture, hunting and forestry sector had the highest incidence of FOI, but they also showed a decrease in FOI from 43.9 in 1996 to 20.8 in 2007. The highest proportion of FOI occurred on Tuesdays (17%) and Wednesdays (18%). Thirty two of the victims had blood alcohol concentration >0.5 parts per thousand. The incidence of FOI in the Arkhangelsk region decreased from 1996 to 2007, but remains high and varies by gender, age and economic activity over time.
Occupational Medicine, Sep. 2010, Vol.60, No.6, p.470-475. Illus. 30 ref.
Fatal_occupational_injuries.pdf [in English]

CIS 11-0699 Onder M., Adiguzel E.
Evaluation of occupational fatalities among underground coal mine workers through hierarchical loglinear models
In this study, hierarchical loglinear analyses were applied to occupational fatalities having occurred in the period of 1980-2004 in the five underground coal mines in Turkey. Accident records were evaluated and the main factors affecting the accidents were defined as mine site, miners' age, occupation and accident type. By taking into account the sub factors of the main factors, multi-way contingency tables were prepared and the probabilities that might affect fatality accidents were investigated. Findings are discussed.
Industrial Health, Nov. 2010, Vol.48, No.6, p.872-878. Illus. 17 ref.
Evaluation_of_occupational_fatalities.pdf [in English]

CIS 11-0715 Tanaka K., Otsubo T., Tanaka M., Kaku A., Nishinoue N., Takanao T., Kamata N., Miyaoka H.
Similarity in predictors between near miss and adverse event among Japanese nurses working at teaching hospitals
Near miss-based analysis has been recently suggested to be more important in the medical field than focusing on adverse events, as in the industrial field. To validate the utility of near miss-based analysis in the medical fields, this study investigated whether or not predictors of near misses and adverse events were similar among nurses at teaching hospitals. Of the 1,860 nurses approached, 1,737 (93.4%) were included in the final analysis. Potential predictors provided for analysis included gender, age, years of nursing experience, frequency of alcohol consumption, work place, ward rotation, frequency of night shifts, sleepiness during work, frequency of feeling unskilled, nurses' job stressors, working conditions, and depression. Ordinal logistic analysis showed that predictors of near misses and adverse events were markedly similar. Parameters that were significantly related to both near misses and adverse events were years of experience, frequency of night shifts, internal ward, and time pressure.
Industrial Health, Nov. 2010, Vol.48, No.6, p.775-782. 36 ref.
Similarity_in_predictors.pdf [in English]

CIS 11-0469 Ho S.C., Wang L.Y., Ho C.K., Yang C.Y.
Fatal occupational injuries in Taiwan, 1994-2005
This study examines the trends in rates of fatal occupational injuries in Taiwan (China) by demographic group and occupation for 1994-2005. Data on deaths due to injuries at work from 1994 through 2005 were obtained from the Department of Health, while employment data were retrieved from the "Employment and Earnings" database of the Directorate-General of Budget and Accounting Statistics. A Poisson regression model was used to examine the trends in rates of fatal occupational injuries in various occupations while controlling for demographic characteristics. Overall fatal occupational injury rates declined during the study period among all demographic groups and occupations. Adjusted annual changes in rates of fatal injuries ranged from a decrease of 13.6% a year in machine operators/related workers to a decrease of 35.9% in clerks. The annual decrement was faster for males than for females and for older workers compared to young workers.
Occupational and Environmental Medicine, Apr. 2010, Vol.67, No.4. p.251-255. Illus. 33 ref.

CIS 11-0157 Forst L., Avila S., Anozie S., Rubin R.
Traumatic occupational injuries in Hispanic and foreign-born workers
Hispanic and foreign-born workers suffer high rates of occupational fatality in the U.S. Reasons for this are not well understood. The aim of this study was to gather information about the details related to severe, non-fatal occupational injuries in this vulnerable population. Eight years of data were obtained from an urban trauma center in the United States. In addition, medical consultations of individuals admitted for an occupational injury during an 8-month period are reported. Hispanics were more highly represented than expected. They were more likely to be injured by machinery and hand tools. Workers reported hazardous working conditions, lack of workers compensation, short time in current employment, and not working in their usual job. Implications of these findings are discussed.
American Journal of Industrial Medicine, 2010, Vol.53, p.344-351. 35 ref.

CIS 11-0032 Reis Oliveira C., Pires C.
Observatório da imigração
Immigration and occupational accidents
Imigração e sinistralidade laboral [in Portuguese]
This publication presents an analysis of Portuguese occupational accident statistics in various sectors of activity and occupations, with a focus on the vulnerability of immigrant workers. Three types of problems are highlighted as being likely to explain the higher rate of accidents among these workers: their precarious employment; language difficulties and cultural differences; lack of information on their rights and responsibilities in the labour market.
Alto-comissariado para a imigração e diálogo intercultural, Rua Álvaro Coutinho 14, 1150-025 Lisbon, Portugal, 2010. 168p. Illus. 84 ref.
Imigração_e_sinistralidade_laboral.pdf [in Portuguese]

CIS 11-0019 Santos G., Mendes F.
The most frequent occupational accidents in Portuguese SMEs
Acidentes de trabalho mais comuns nas PME portuguesas [in Portuguese]
This article on the most common occupational accidents in Portuguese SMEs highlights the importance of OSH management systems. It is based on the findings of a survey conducted among SMEs certified according to ISO 9001. Of the 46 enterprises surveyed, seven also applied for and obtained OHSAS 18001 certification. The motivations for this additional certification and the benefits derived are discussed. Finally, the article presents and comments key statistics for the most common accidents in Portuguese SMEs.
Segurança, Nov.-Dec. 2010, Vol.XLV, No.199, p.30-34. Illus. 10 ref.

CIS 10-0574 Kakimoto Y.
Some problems of human factors approaches in aviation accident investigation
Kōkū jiko chōsa taisei ni tsuite - Hyūman fakutā apurōchi no mondaiten [in Japanese]
The Science Council of Japan and Japanese victims family groups have advanced opinions as to how to carry out accident investigations better than before. This paper attempts to analyse the following points: (1) the purpose of accident investigation; (2) priorities in such investigations; (3) should human errors in organizations be tackled through criminal law?; (4) use of accident investigation reports in trials; (5) the hiring of human factor specialists as investigators and commission members; (6) the use of various models of human factors.
Journal of Science of Labour - Rōdō Kagaku, 2010, Vol.86, No.2, p.105-112. 10 ref.

CIS 10-0386 Du C.L., Wang J.D., Chu P.C., Guo Y.L.
Acute expanded perlite exposure with persistent reactive airway dysfunction syndrome
After an accidental release of expanded perlite powder in a factory in Taiwan, 24 exposed workers were followed for more than six months. Three developed persisting respiratory symptoms with positive provocation tests that were compatible with a reactive airway dysfunction syndrome. During an experimental simulation of the accident, expanded perlite was shown to be very dusty, with airborne concentrations greatly exceeding current exposure limits. A review of literature showed that while exposure of expanded perlite below current permissible levels may be generally safe, precautionary protection of short-term exposure to high concentrations is warranted.
Industrial Health, Jan. 2010, Vol.48, No.1, p.119-122. 14 ref.
Acute_expanded_perlite_exposure.pdf [in English]

CIS 10-0372 Hon C.K.H., Chan A.P.C., Wong F.K.W.
An analysis for the causes of accidents of repair, maintenance, alteration and addition works in Hong Kong
This study unveils causes of accidents in repair, maintenance, alteration and addition (RMAA) work. RMAA work is playing an increasingly important role in developed societies, including Hong Kong. Safety problems associated with RMAA work in Hong Kong has reached an alarming level. In view of rapid expansion of the RMAA sector and rising proportion of accidents in the construction industry, there is a pressing need to investigate causes of RMAA accidents. Structured interviews were conducted with RMAA contractors to explore causes of accidents in the RMAA sector. A two-round Delphi method with 13 safety experts was subsequently employed to verify the interview findings and rank the relative degree of importance for various causes of accidents. Accidents happen in RMAA work due to an intersection of reasons. One of the root causes of accidents is low safety awareness of RMAA workers; however, wider organizational and industrial factors are not negligible. This study sheds light on why accidents happen in the RMAA sector. Only when the factors leading to accidents are identified can effective measures be made.
Safety Science, Aug. 2010, Vol.48, No.7, p.894-901. 26 ref.

CIS 10-0317 Wu W., Gibbb A.G.F, Li Q.
Accident precursors and near misses on construction sites: An investigative tool to derive information from accident databases
Safety problems on construction sites seem to be largely unresolved as the fatality and injury records in construction continue to plague the industry across the world. The lack of an effective system to interrupt and prevent the precursors and contributory factors on construction sites is argued to be the critical deficiency of existent research and practice. This study proposes a feasible approach to facilitate acquiring more useful information from historical records of accidents in order to improve safety on construction sites. A systematic model of improving safety on construction sites is presented to consummate and perfect existent safety-improving systems on construction sites by reinforcing and accentuating the real-time tracking of precursors and immediate factors.
Safety Science, Aug. 2010, Vol.48, No.7, p.845-858. Illus. 56 ref.

CIS 10-0316 Smith D.R., Attia J., McEvoy M.
Exploring new frontiers in occupational epidemiology: The Hunter Community Study (HCS) from Australia
This article describes a pioneering longitudinal investigation known as the Hunter Community Study (HCS), which investigates retired and near-retired persons randomly selected in a regional area on the heavily- populated east coast of Australia. Data collected include clinical and biological measures, as well as the full lifetime occupational history linked to job exposures. Longitudinal cohort studies with exposure assessment, such as the HCS offer epidemiologists a clear opportunity for examining and evaluating the long-term risks of employment across a variety of workplace settings.
Industrial Health, Mar. 2010, Vol.48, No.2, p.244-248. 47 ref.
Exploring_new_frontiers.pdf [in English]

2009

CIS 11-0166 Marucci-Wellman H., Leamon T.B., Binh T.T.T., Diep N.B., Wegman D.H., Kriebel D.
A survey of work-related injury in a rapidly-industrializing commune in Vietnam
This cross-sectional survey was administered by health volunteers to all households in a rapidly-industrializing commune in Vietnam to collect information on the characteristics of work and injuries during the previous month. Of all households, 2615 (99%) completed the survey, comprising 10,416 residents and 5485 workers with 8478 jobs. Respondents reported 591 injuries (an annualized incidence rate [IR] of 681 per 1000 residents), 482 (82%) of which occurred during work activities (annualized IR of 1011 per 1000 full-time equivalents). Non-agricultural work was more hazardous than agricultural work (1033 vs. 844 injuries per 1000 full-time equivalents, respectively). Working at home was prevalent, with 28% of households having a family-owned business. The injury IRs in this study were approximately 10 times higher than those reported in prior studies from Vietnam. High injury rates represent a substantial economic and social burden on a rapidly industrializing country and underscore the importance of injury prevention guided by surveillance data.
International Journal of Occupational and Environmental Health, Jan.-Mar. 2009, Vol.15, No.1, p.1-8. 19 ref.

CIS 11-0038 Prat T., Gauthier F.
A study of accident investigation and analysis practices in thirteen Quebec businesses
Etude des pratiques relatives à l'enquête et à l'analyse des accidents dans treize établissements québécois [in French]
Accident investigation and analysis practices are described in literature and in occupational safety and health management systems as an essential prevention activity. Although there are numerous literature references describing the main investigation techniques, none of the approaches appear to have been universally adopted and their implementation remains mostly undocumented. The overall objective of this study was to better understand how accident investigation and analysis is carried out by studying the practices of a number of Quebec businesses, in order to identify good practices and possible improvements. Findings are discussed.
Travail et santé, June 2009, Vol.25, No.2, p.25-31. 21 ref.

CIS 10-0170 Ensinger W.
Specialized underground engineering in Europe - Analysis of accidents having occurred between 1998 and 2008
Spezialtiefbau in Europa - Analyse des Unfallgeschehens in den Jahren 1998 bis 2008 [in German]
This article analyses approximately 4000 accidents having occurred between 1998 and 2008 in specialized underground engineering work in 13 European countries, on the basis of accident reports. The results are expressed by sector of activity, age group, hour of day, day of the week, shift duration, type of job and accident cause. Data on the location of injury and the severity rate by age group are also presented.
Tiefbau, Apr. 2009, Vol.121, No.4, p.220-224. Illus.

CIS 09-977 Grabowski M., You Z., Zhou Z., Song H., Steward M., Steward B.
Human and organizational error data challenges in complex, large-scale systems
In complex, large-scale systems, event analyses are constrained by the quality of the gathered data, the maturity of the associated reporting system, and the training and background of the investigator. Such constraints place limits on the adequacy and strength of analyses conducted with the data. This article focuses on the challenges of measuring performance variability in complex systems. It presents an overview of human and organizational error assessments and introduces the particular challenges of data needs in human reliability analyses. A case study of human and organizational error analysis in a complex, large-scale system, marine transportation in inland waterways in the northwestern United States, is used to illustrate data challenges in risk assessment processes.
Safety Science, Oct. 2009, Vol.47, No.8, p.1185-1194. Illus. 40 ref.

2008

CIS 12-0020 Analysis of fatal occupational accidents in Rio Grande do Sul
Análises de acidentes do trabalho fatais no Rio Grande do Sul [in Portuguese]
Contents of this report on fatal occupational accidents in the Brazilian province of Rio Grande do Sul: definitions of occupational accidents and fatal accidents with reference to Brazilian regulations; penalties and infringements of regulations; accidents involving children and adolescents; descriptive reports of 35 selected cases of fatal occupational accidents having occurred in the province since 2001.
Ministerio do trabalho e emprego, Superintendência regional do trabalho e emprego do Rio Grande do Sul, Av. Mauá 1013, Centro, 90010-110 Porto Alegre, Brazil, 2008. 335p. Illus, 25 ref.
Análises_de_acidentes_do_trabalho_fatais_[INTERNET_FREE_ACCESS] [in Portuguese]

CIS 10-0761
Ministério do Trabalho e Emprego
Analyses of fatal occupational accidents in Rio Grande do Sul - An experience of the Section of Workers' Occupational Safety and Health
Análises de acidentes do trabalho fatais no Rio Grande do Sul - A experiência da Seção de Segurança e Saúde do Trabalhador [in Portuguese]
This book presents fatal accidents notified between August 2001 and December 2007 in Rio Grande do Sul, Brazil, together with detailed studies of the causes of 35 accidents having occurred in various sectors of activity, in order to draw useful conclusions.
Superintendêcia Regional do Trabalho e Emprego do Rio Grande do Sul, Seção de Segurança e Saúde do Trabalhador (SEGUR), Av. Mauá 1013, 90010-10 Porto Alegre, Brazil, 2008. 335p. Illus. 25 ref.
Análises_de_acidentes.pdf [in Portuguese]

CIS 10-0720 Giraud L., Ait-Kadi D., Ledoux E., Paques J.J., Tanchoux S.
Maintenance - State of knowledge and exploratory study
La maintenance - Etat de la connaissance et étude exploratoire [in French]
The objectives of this study were: to determine whether relationships exist between maintenance activities and occupational safety and health; to describe the present state of the maintenance sector; to review literature relating to maintenance and OHS; and to develop a thematic research programme. The report also includes an analysis of maintenance accidents having occurred in Quebec. The report discusses lockout, machine design, confined spaces and belt conveyors. Areas for future research are proposed, to fill some of the gaps noted during the study or to generate new solutions for the problems identified.
Institut de recherche Robert-Sauvé en santé et en sécurité du travail du Québec (IRSST), 505 boul. de Maisonneuve Ouest, Montreal (Quebec) H3A 3C2, Canada, 2008. ix, 47p. Illus. 59 ref. Price: CAD 7.35. Downloadable version (PDF format) free of charge.
Rapport_R-578.pdf [in French]

CIS 10-0018 We're ready - IAPA 2008 annual review
Report of activities of the Industrial Accident Prevention Association of the Province of Ontario, Canada, for the year 2008. Contents include key accident statistics, programmes for supporting innovation, main actions and achievements, volunteering and governance.
Industrial Accident Prevention Association (IAPA), Centre for Health & Safety Innovation, 5110 Creekbank Road, Suite 300, Mississauga, ON L4W 0A1, Canada, 2008. 38p. Illus.
We're ready - IAPA 2008 annual review [in English]

CIS 09-273 McLoughlin K.
Looking below the surface
More than 200 people die each year in the United Kingdom in occupational accidents, some of which may result in prosecutions. What is a certainty, however, is the involvement of the coroner. This article explains why it is important that employers and practitioners understand the role and significance of the inquest in the aftermath of tragedy.
Safety and Health Practitioner, Oct. 2008, Vol.26, No.10, p.54-56. Illus. 6 ref.

2007

CIS 11-0033 Jacinto C.
Analysis of occupational accidents - The WAIT (Work Accidents Investigation Technique) method
Análise de acidentes do trabalho - Método de investigação WAIT (Work Accidents Investigation Technique) [in Portuguese]
This publication presents a practical, novel and sound research method as a support for analyzing occupational accidents. Entitled WAIT (Work Accidents Investigation Technique), it comprises two phases: a simplified research phase during which the most immediate causes and circumstances are analyzed, taking into account legal requirements, followed by a detailed and in-depth analysis during which other causal factors are identified and evaluated, such as possible organizational or overall managerial weaknesses. The various steps of the method are described and examples of its application are presented in a table. Full texts of the relevant legislation are also included.
Verlag Dashöfer, Edições Proffisionais Unip,. Lda., Edifício Heron Castilho, Rua Braamcamp 40, 1250-050 Lisbon, Portugal, 2007. 164p. Illus.

CIS 08-1257 Vilela R.A.G., Mendes R.W.B., Gonçalves C.A.H.
Occupational accidents investigated by CEREST Piracicaba: Confronting the traditional approach of safety at work
Acidente do trabalho investigado pelo CEREST Piracicaba: confrontando a abordagem tradicional da segurança do trabalho [in Portuguese]
Enterprises mostly present simplistic explanations of occupational accidents, whereby the victims are blamed for the events, and aspects of work organization or equipment design get ignored. This article presents the analysis of occupational accident data conducted by the System of Surveillance of Occupational Accidents (SIVAT) at the Centre of Reference on Workers' Health (CEREST) in Piracicaba, Brazil, using cases notified by all emergency rooms and hospitals of the municipal district. The methodology involves interviews, analysis of documents, photographic records, observation and investigation. Such an approach could suggest solutions for safety improvements.
Revista brasileira de saúde ocupacional, Jan.-June 2007, Vol.32, No.115, p.29-40. Illus. 26 ref.
http://www.fundacentro.gov.br/rbso/BancoAnexos/RBSO%20115%20Acidente%20investigado%20pelo%20Cerest.pdf [in Portuguese]

CIS 07-1328 Fuchs M.
Medical aspects of the accident investigation procedure
Medizinische Aspekte im Rahmen des Abklärungsverfahrens nach Unfällen [in German]
Aspects médicaux de la procédure d'instruction après accident [in French]
This article comments Swiss regulations that apply to the medical investigation procedure following an accident, in light of the most recent Swiss court rulings. Contents: legal directives and their application in medical practice (legal grounds and preliminary remarks, principles concerning treatment specified in accident insurance law, differences between medical treatment and medical examination, directives for the inquest and for establishing the facts, as well as for weighing the evidence, remarks concerning the medical evidence); quantitative data concerning accident insurance and the organization of medical services by the Swiss accident insurance institution (SUVA) and private insurance firms.
Informations médicales - Medizinische Mitteilungen, 2007, No.78, p.33-56.
https://wwwsapp1.suva.ch/sap/public/bc/its/mimes/zwaswo/99/pdf/02869_78_d.pdf ((part)) [in German]
https://wwwsapp1.suva.ch/sap/public/bc/its/mimes/zwaswo/99/pdf/02869_78_f.pdf ((part)) [in French]

2006

CIS 07-542 Francis S., Paddon F.
Best behaviour
This article provides guidance for safety and health professionals in the United Kingdom on ethical issues related to workplace accident investigations. Topics addressed: professional conduct; professional obligations; conflicts of interest; role of safety inspectors; dealing with accusations of obstruction; balancing conflicting obligations; dealing with a personal conflict of interest.
Safety and Health Practitioner, July 2006, Vol.24, No.7, p.32-34. Illus. 3 ref.

2005

CIS 11-0121 Paridon H.
How trip, slip and fall accidents originate
Entstehung von Stolper-, Rutsch- und Sturzunfällen [in German]
Based on a literature survey, this study deals with accidents that can be characterized as slips, trips or falls (STF). A first section briefly illustrates the basic principles involved in the process of walking. This is followed by a listing of accident causes. The third section addresses more specifically the psychological aspects of accident origination. It becomes clear that a series of information processing principles exist, which can contribute to accidents, but which also, simultaneously, are exactly those that enable us to live and work in an effective manner. The fourth section presents the findings of investigations regarding STF accidents. Indications are that while technical faults can frequently be identified as the cause, human factors tend to be less significant in this regard. Finally, several proposals are forwarded regarding preventative measures.
Hauptverband der gewerblichen Berufsgenossenschaften (HVBG), Alte Heerstrasse 111, 53754 Sankt Augustin, Germany, 2005. 55p. Illus. 67 ref.
Report_1/05.pdf [in German]

CIS 07-1273
Health and Safety Executive
A review of safety culture and safety climate literature for the development of the safety culture inspection toolkit
Following the recommendations made from inquiries into several major railway accidents in the United Kingdom, the Railway Inspectorate requested that a safety culture inspection toolkit be developed. The toolkit was required to provide a pragmatic approach for the measurement of safety culture in rail organizations. The Inspectorate requested that the approach should focus on a limited number of indicators that are known to influence safety culture. The first phase of the project described in this report consisted of a literature review, in which the five indicators found to be the most relevant were leadership, two-way communications, employee involvement, learning culture and attitude towards blame.
HSE Books, P.O. Box 1999, Sudbury, Suffolk CO10 2WA, United Kingdom, 2005. viii, 42p. Illus. 66 ref. Price: GBP 10.00. Downloadable version free of charge.
http://www.hse.gov.uk/research/rrpdf/rr367.pdf [in English]

CIS 06-763 Occupational accident investigations
Investigación de accidentes laborales [in Spanish]
This article describes a method for conducting accident investigations. The investigation consists of several stages: designating an investigation team; field work plan (search for evidence, photographs, video recordings or sketches, measurements, interviews of witnesses); analysis of the findings; conclusions and recommendations for improvement; investigation report (preliminary and final report, presentation of the results).
Prevención, Oct.-Dec. 2005, No.174, p.50-57. Illus. 4 ref.

CIS 06-492 Gordon R., Flin R., Mearns K.
Designing and evaluating a human factors investigation tool (HFIT) for accident analysis
In an attempt to improve the investigation of the human factors causes of accidents in the United Kingdom offshore industry, a Human Factors Investigation Tool (HFIT) was developed. It collects four types of human factors information: action errors occurring immediately prior to the incident; error recovery mechanisms, in the case of near misses; thought processes which lead to the action error; underlying causes. The tool was evaluated on the basis of an inter-rater reliability assessment, usability assessment, case studies and an established evaluation method. Although there is a need for further validation and analysis of HFIT using more realistic accident scenario exercises, it was found to be useful for the development of remedial actions, one of the main objectives of the tool.
Safety Science, Mar. 2005, Vol.43, No.3, p.147-171. Illus. 38 ref.

2004

CIS 05-25 Ibabe Erostarbe I., Sorozábal Ostolaza J.M., Fraile Cantalejo A., Pérez Bilbao J.
Vulnerability of data collection in accident investigations - Application of testimony psychology
La vulnerabilidad de la toma de datos en la investigación de accidentes de trabajo - Aplicación de la psicología del testimonio [in Spanish]
Spanish law on the prevention of hazards requires that enterprises conduct an investigation to determine the causes of accidents in order to implement preventive actions. The investigation, which involves several steps, starts with the collection of clues and testimonies. Collecting testimony is a complex process that involves psychological mechanisms (perception, memory and factual accounts). This article analyses the specific aspects of this process and shows how psychology can be applied to the collecting of testimony, in particular by applying communication strategies and by choosing appropriate questions to be asked when interviewing witnesses in order to obtain precise information.
Prevención, trabajo y salud, 2004, No.29, p.25-40. Illus. 26 ref.
http://www.mtas.es/insht/revista/revista29_04.htm [in Spanish]

CIS 04-716 Denis M.A., Ecochard R., Bernadet A., Forissier M.F., Porst J.M., Robert O., Volckmann C., Bergeret A.
Blood exposure incidents: Importance of an early warning system
Accidents d'exposition au sang: intérêt d'un "système sentinelle" [in French]
This study highlights the importance of an early warning system for blood exposure incidents for determining case-by-case preventive actions when it is observed that a specific health care action presents a higher-than-expected frequency of incident occurrence (warning threshold). It presents the results of a database compilation of incidents having occurred in public hospitals in Lyon, France, between 1996 and 2003, together with their analysis. This analysis led to the evaluation and selection of safety equipment and enabled the introduction of specific and sustainable preventive and collaborative measures.
Documents pour le médecin du travail, 3rd Quarter 2004, No.99, p.383-387. 8 ref.

CIS 04-445 The radiological accident in Cochabamba
In April 2002 an accident involving an industrial radiography source containing ¹⁹²Ir occurred in Bolivia. The source, which was later found not to have been fully confined, was transported 500km from Cochabamba to La Paz as cargo on a passenger bus. The bus had a full load of passengers for most of the eight hour journey. The equipment was subsequently transferred by taxi to the company's shielded facility. This report gives an account of the event, the doses received and the medical assessment. It also presents information relevant to national authorities and regulatory organizations, emergency planners and a broad range of specialists, including physicists, radiation protection officers and medical specialists, for the purpose of helping reduce the likelihood of similar accidents occurring or, were they do occur, to mitigate their consequences.
International Atomic Energy Agency (IAEA), Wagramerstrasse 5, P.O. Box 100, 1400 Wien, Austria, 2004. 54p. Illus. 16 . Price: EUR 19.00.
http://www-pub.iaea.org/MTCD/publications/PDF/Pub1199_web.pdf [in English]

CIS 04-307 Layne L.A.
Occupational injury mortality surveillance in the United States: An examination of census counts from two different surveillance systems, 1992-1997
This article compares occupational injury mortality data from the National Traumatic Occupational Fatalities (NTOF) surveillance system and the Census of Fatal Occupational Injuries (CFOI) in the United States from 1992 to 1997. There were 31,643 cases according to NTOF and 37,023 from CFOI for workers 16-years and older in the United States for the 6-year period of analysis. The annual average occupational injury mortality rates were 4.5 per 100,000 workers from NTOF and 5.2 from CFOI. While NTOF provides data dating back to 1980, CFOI (established in 1992) provides a more comprehensive and detailed picture of occupational injury mortality. The overall injury mortality patterns, however, appear to be similar between the systems.
American Journal of Industrial Medicine, Jan. 2004, Vol.45, No.1, p.1-13. Illus. 33 ref.

CIS 04-391 Schröder J.U.
Bundesanstalt für Arbeitsschutz und Arbeitsmedizin
Data collection of causes and underlying factors of marine casualties
Datenerfassung bei Unfallursachen und begünstigenden Faktoren für Unfälle in der Seeschifffahrt [in German]
This study examines the international efforts undertaken to investigate maritime accidents. It focuses on the approaches used to obtain structured accident data in order to form a solid statistical basis for the assessment of existing maritime safety standards and the development of new standards. A casualty investigation follow-up method was developed, based on a process model of the maritime casualty (SEMOMAP) and data scheme. It was used to obtain data on accident processes and their underlying factors. Although the number of maritime accidents was not sufficient to enable general conclusions regarding causes, it was clear that there were gaps in the reports concerning the influencing factors of crew performance. Consequently, the accident process often cannot be modelled for safety scientific purposes on the basis of casualty reports. This underlines the need for a more structured approach in future.
Wirtschaftsverlag NW, Postfach 10 11 10, 27511 Bremerhaven, Germany, 2004. 203p. Illus. 88 ref. Price: EUR 17.50.
http://www.baua.de/info/s/s81.pdf [in German]

CIS 04-67
Health and Safety Executive
Investigating accidents and incidents - A workbook for employers, unions, safety representatives and safety professionals
This guidance on how to investigate accidents and incidents, including near misses, was prepared in consultation with industry, unions and health and safety professional bodies. It is intended as a first step in introducing organizations to the benefits of carrying out investigations and the methods by which accidents should be recorded, investigated and the findings acted upon. The guidance is aimed primarily at SMEs where it is often difficult to build up an expertise in investigating, although larger organizations may also find it helpful. The four steps featured in the guidance are: the gathering of information; the analysing of information; identifying risk control measures; the action plan and its implementation.
HSE Books, P.O. Box 1999, Sudbury, Suffolk CO10 2WA, United Kingdom, 2004. iv, 82p. Illus. 19 ref. Price: GBP 9.50.

CIS 03-1504 Decree No.30 of 15 Jan. 2004 on the investigation and registration of occupational accidents and diseases [Belarus]
Pravila rassledovanija i učeta nesčastnyh slučaev na proizvodstve i professional'nyh zabolevanij [in Russian]
This Decree, issued in accordance with Presidential Decree No.18 of 30 July 2003 concerning compulsory insurance against occupational diseases and accidents, establishes the rules for their investigation and notification/registration.
Nacional'nyj Reestr Pravovyh Aktov, 26 Jan. 2004, No.8, p.4-15.

2003

CIS 03-1552 Dudka G.
Recording and analysis of incidents
Rejestrowanie i analiza wydarzeń wypadkowych bezurazowych [in Polish]
The growing number of enterprises which implement health and safety management systems has contributed to an increased interest in the recording of incidents. This kind of recording system gathers data related to accident threats before they occur. The analysis of these records can help in the implementation of successful accident prevention programmes.
Bezpieczeństwo pracy, May 2003, No.5, p.26-28. Illus. 4 ref.

CIS 03-1398 Male G.E.
Health and Safety Executive
Safety and industrial lift trucks: A survey of investigated accidents and incidents [April 1997 to March 2001]
This report analyses the 1204 accidents and incidents associated with industrial lift trucks in the United Kingdom which were investigated by HSE inspectors between April 1997 and March 2001. It identifies a number of common reasons for accidents and incidents. It is intended to provide information to assist in the development of safety requirements for the design and use of these machines and to assist in the training of drivers and others affected by industrial truck use. Contents: survey scope and nature; details of survey; person injured; driver training; nature of accidents; truck operation; causal factors; discussion; conclusions.
HSE Books, P.O. Box 1999, Sudbury, Suffolk CO10 2WA, United Kingdom, 2003. viii, 47p. Illus. Price: GBP 10.00.
http://www.hse.gov.uk/pubns/sir60.pdf [in English]

CIS 03-681 Chaturvedi A.K., Smith D.R., Soper J.W., Canfield D.V., Whinnery J.E.
Characteristics and toxicological processing of postmortem pilot specimens from fatal civil aviation accidents
Autopsied biological samples from civil aviation accident pilot fatalities are submitted to the Civil Aerospace Medical Institute (CAMI) for toxicological evaluation. However, such evaluation is dependent on types and amounts of submitted samples, and obtaining suitable samples is governed by the nature of the accident. The characteristics of these samples and their toxicological processing have not been well documented in the literature. Therefore, the CAMI Toxicology Database was searched for these aspects. It was found that the toxicologically preferred samples of blood and urine were available in 78% and 56% of the cases, respectively. Other samples were also frequently available. Samples were primarily analyzed for combustion gases, alcohol and drugs. An effective quality control is maintained throughout the process. It is concluded that in the majority of the aviation accidents, sufficient amounts and types of biological samples were submitted for toxicological evaluation.
Aviation, Space, and Environmental Medicine, Mar. 2003, Vol.74, No.3, p.252-259. Illus. 20 ref.

2002

CIS 03-900 Stanislaw H.
Computer-intensive methods in traffic safety research
The analysis of traffic safety data archives has been markedly facilitated by the development of procedures that are heavily dependent on computers. Three such procedures are described in this article: the first involves using computers to assist in the identification and correction of invalid data; the second makes greater computational demands, and involves using computerized algorithms to fill in the "gaps" that typically occur in archival data when information regarding key variables is not available; finally, the third and most computer-intensive procedure involves using data mining techniques to search archives for interesting and important relationships between variables. These procedures are illustrated using examples from data archives that describe the characteristics of traffic accidents in the USA and Australia.
International Journal of Occupational Safety and Ergonomics, 2002, Vol.8, No.3, p.353-363. Illus. 10 ref.

CIS 02-1873 Kinsman P., Lewis J.
Health and Safety Executive
Report on a second study of pipeline accidents using the Health and Safety Executive's risk assessment programs MISHAP and PIPERS
HSE uses mathematical models to estimate risks when examining proposals to develop land in the vicinity of high-pressure pipelines. PIPERS and MISHAP are computer programs based on these models. An earlier version of MISHAP, called MISHAP98, was not sufficiently conservative in some respects, and it was recommended that improvements be made. These have now been implemented and the present work examines the performance of the new version, called MISHAP01 that is now the routine tool for studying natural gas pipelines. PIPERS is an extension and development version of MISHAP, embodying alternative ways of modelling releases from natural gas pipelines and having additional models for use in the study of risks in the vicinity of pipelines carrying flashing and non-flashing liquids. Over 100 reports of pipeline accidents were studied using these programmes, and recommendations are made concerning their applicability and areas for further improvement.
HSE Books, P.O. Box 1999, Sudbury, Suffolk CO10 2WA, United Kingdom, 2002. ii, 429p. Illus. Price: GBP 25.00.
http://www.hse.gov.uk/research/rrpdf/rr036.pdf [in English]

CIS 02-644 Company internal accident investigations: Let's avoid this happening again
Enquête d'accident interne à l'entreprise: évitons que cela ne se reproduise [in French]
Betriebsinterne Unfallabklärung: Damit es nicht wieder passiert/L'indagine d'infortunio aziendale [in German]
Per evitare che possa ripetersi [in Italian]
This booklet presents a method for carrying out company internal analyses of accident causes that enable the identification of the underlying causes and the adoption of preventive measures that are effective over the long term. The method consists of the following steps: establish the facts; determine the causes; define measures; keep records of the results of the investigations; inform concerned persons; control the implementation. Forms and check-lists for carrying out each step are included.
Suva, Arbeitssicherheit, Postfach, 6002 Luzern, Switzerland, 1st ed., Jan. 2002. 8p. Illus.

2001

CIS 02-121 Meliá Navarro J.L., Chisvert Perales M.J., Pardo E.
Consequences of the attribution of accident causes for their notification and investigation
Las consecuencias de las atribuciones de las causas de los accidentes para la notificación e investigación de los mismos [in Spanish]
In order to plan the preventive actions needed to avoid further accidents and health hazards, safety and health professionals rely on essential elements which include information on risks, communication systems within the enterprise concerning accidents and accident investigation reports. During the collection, selection and transmission of this information, various attribution processes take place which can affect its reliability. Victims or witnesses of accidents could for example be inclined to give erroneous or conflicting information. This deviation of the information also influences attitudes towards safety and can affect the efficiency of preventive measures. This article analyses this issue from the psychological angle and presents a few guidelines for improving the quality of safety information, encouraging better attitudes towards safety and developing more effective preventive measures.
Prevención, July-Sep. 2001, No.157, p.16-30. Illus. 12 ref.

CIS 02-137 Henderson J., Whittington C., Wright K.
Health and Safety Executive
Accident investigation - The drivers, methods and outcomes
Proposed legislation in the United Kingdom will require employers to investigate the causes of work-related accidents and ill health. The objective of this study was to provide guidance for Health and Safety Executive (HSE) as to the support which industry may need to implement these requirements. The study involved a telephone survey (1500 cases) followed by a smaller face-to-face interview survey (100 companies). The results of the telephone survey were reported in an earlier report. This report covers the interview survey. It describes the technical approach adopted in the survey, a summary of key findings, a comparison of these findings with the output from the telephone survey and, finally, the implications of the findings for the HSE. These include the need to reinforce the links between risk assessment and accident investigation, to provide industry with additional technical support and improved access to HSE information, to provide better support for training in accident investigation, and finally to participate in improving the current legal climate.
HSE Books, P.O. Box 1999, Sudbury, Suffolk CO10 2WA, United Kingdom, 2001. vi, 432p. Illus. Price: GBP 25.00.

CIS 01-1659 Livingston A.D., Jackson G., Priestley K.
Health and Safety Executive
Root causes analysis: Literature review
To learn from past failures, organizations need to adopt investigation techniques that explicitly identify root causes of incidents. Root causes analysis is a method designed to help investigators determine what, how and why an incident occurred. There are three key components that need to be present to ensure effective incident investigation: describing the incident sequence and its contributing conditions; identifying the critical events or active failures in the incident sequence; systematically investigating the organizational factors that allowed the active failures to occur. The method selected should specifically facilitate the identification of safety management and organizational inadequacies and the factors that exert control over the design, development, maintenance and review of risk control systems and procedures.
HSE Books, P.O. Box 1999, Sudbury, Suffolk CO10 2WA, United Kingdom, 2001. vi, 53p. Illus. 47 ref. Price: GBP 10.00.

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