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Accident investigation

The main purpose of accident investigation is to improve safety performance (улучшить эффективность безопасности) by:

  1. exploring the reasons for the event and identifying both the immediate causes (непосредственные причины) and underlying causes (первопричины, основные причины),

  2. identifying the remedial action (исправительные действия) to improve the safety management system by improving risk control, preventing a recurrence (повторение) and reducing financial losses.

The only cure for accidents is prevention.

An accident is a hazardous occurrence which results in an injury to personnel.

An incident is a hazardous occurrence which has resulted in physical damage to the ship, her cargo, property or the environment. It also includes breaches of security such as pirates and stowaways.

A near miss (потенциально опасное происшествие) is a hazardous event which does NOT result in accident / injury but a situation has arisen where an accident or an incident could have happened.

Some examples of near misses which occur during day-to-day activities:

  • A seaman is found aloft (на высоте) not wearing a safety harness,

  • Acid is spilled while filling up emergency batteries,

  • A cargo net breaks while taking on stores but there is no damage,

  • Emergency action is required to avoid collision.

Examples of an incident and an accident:

Heavy cargo is being moved by an overhead crane and the sling breaks.

  • Some of the cargo drops and hits some equipment, resulting in damage but no injury (incident).

  • Some of the cargo hits a person working in the area. This is an injury accident.

Accidents which can be defined as minor are cut, bruise (синяк) or graze (ссадина, царапина),

Major accidents are broken bones, loss of limb, disability injury (потеря трудоспособности)

Accidents defined as 'serious' include those which involve death, severe injury or severe ill-health (серьёзное ухудшение здоровья).

Near misses should be reported to a Senior Officer or the Master who will complete a near miss report to send to the office.

  • Near miss reports should be completed in full so that a complete picture of the incident can be built up.

  • Near miss reports do not need to be signed.

  • Once received by the office a near miss will be analysed and compared to other near misses. In this way, trends can be identified and changes put in place to improve safety onboard.

  • Near miss reports should be filed onboard so that action can be followed up and they can be accessed by external examiners / auditors.

An accident will normally have three cause levels:

  1. direct / immediate causes

  2. basic / root causes

  3. control management failure.

The direct / immediate cause of an accident can be defined as a problem that, if corrected, could have prevented an incident from occurring or have significantly reduced the incident's consequences.

The basic / root cause can be defined as the most basic cause that can be reasonably identified that management has control to fix, and when fixed, will prevent, or significantly reduce the likelihood of the problem's recurrence. The root causes are the reason why substandard acts / conditions occur; the factors that, when identified, permit meaningful management control.

Control management failure: 'management' refers not to the senior management of the Company but to the management system – be it on the bridge or in the office.

Direct/Surface causes are usually due to substandard acts and substandard conditions.

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