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MODERN METHOD ON ACCIDENT INVESTIGATION

This document outlines advanced methodologies for investigating accidents, emphasizing how to prevent incidents in nuclear power plants (NPPs). It covers the systematic assessment of significant events, identifying direct and root causes, and formulating corrective actions. Using case studies like the tragic accident at Kaiga 3&4, the text illustrates steps in accident investigation, including event narration, chronology building, and logic tree analysis. By applying these methods broadly, organizations can enhance safety oversight and effectively mitigate risks in any industrial setting.

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MODERN METHOD ON ACCIDENT INVESTIGATION

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  1. MODERN METHOD ON ACCIDENT INVESTIGATION V.P.GHOLAP V.LAKSHMAN S.BHATTACHARYA P.K.GHOSH AERB

  2. ASSET • ASSESSMENT OF SAFETY SIGNIFICANT EVENTS TEAM • DEVISED BY IAEA - • PREVENTION OF INCIDENTS - NPPS • ENSURE CONSISTENCY AND COMPREHENSIVENESS OF THE REVIEW OF INCIDENT INVESTIGATIONS

  3. ASSET APPROACH-PHILOSOPY • EVENTS – Occur - because of • FAILURE - to perform as expected- due to • LATENT WEAKNESS - not timely eliminated - (direct cause) • DEFICIENCIES OF PLANT SURVEILLANCE PROGRAMME - on equipment, personnel and procedures (root cause)

  4. ASSET METHODOLOGY • SELECTION OF OCCURRENCES • IDENTIFICATION OF DIRECT CAUSE • IDENTIFICATION OF ROOT CAUSE • DETERMINATION OF CORRECTIVE ACTIONS • GENERIC LESSONS

  5. ASSET METHODOLOGY -1 • SELECTION OF OCCURRENCES • ELEMENT THAT FAILED TO PERFORM AS EXPECTED- TO BE IDENTIFIED

  6. ASSET METHODOLOGY-2 • IDENTIFICATION OF DIRECT CAUSE • LATENT WEAKNESS OF PERSONNEL, EQUIPMENT OR PROCEDURE

  7. ASSET METHODOLOGY -3 • IDENTIFICATION OF ROOT CAUSE • DEFICIENCY IN DETECTION OF ERROR AND RESTORATION OF ROOT CAUSE

  8. ASSET METHODOLOGY-4 • DETERMINATION OF CORRECTIVE ACTIONS • GENERIC LESSONS

  9. INVESTIGATION STEPS • NARRATION OF EVENT • BUILD CHRONOLOGICAL SEQUENCE • BUILD LOGIC TREE • IDENTIFY NATURE OF OCCURRENCES (EQUIPMENT, PROCEDURE OR PERSONNEL)

  10. INVESTIGATION STEPS..contd. • IDENTIFY DIRECT CAUSE • IDENTIFY ROOT CAUSE • DETERMINE CORRECTIVE ACTIONS FOR EACH OCCURRENCE • ACTION PLAN FOR REMEDY

  11. Case Study- Fatal Accident at Kaiga 3&4 • Occurrence Narrative: 1 Gopal Biswas- electrocuted and succumbed to injury while working with portable power saw for cutting wooden runner batten. 2 The job started in an open area in -at 1530 hrs when electrical connection was established for power-saw without the sub distribution board ELCB. 3 Before 1720 hrs, rain started and Shri Biswas left the power saw in open in the rain and returned when rain stopped. 4 As soon as he switched on the power saw and held it by hand he received electric shock. 5 He was shifted to hospital where he was declared dead.

  12. Case Study- Fatal Accident at Kaiga 3&4 • Chronological Sequence: 1530 hrs work started 1700 hrs- rain started 1720 hrs – rain stopped 1720 hrs – portable saw was switched on and the user suffered electrocution 1730 hrs operator was taken to hospital declared and dead.

  13. Case Study- Fatal Accident at Kaiga 3&4

  14. Case Study- Fatal Accident at Kaiga 3&4

  15. Case StudyFatal Accident at Kaiga 3&4

  16. APPLICABILITY • APPLICABLE TO ANY INDUSTRIAL ACTIVITY WHERE THE INDUSTRY’S MANAGEMENT OR THE RELEVANT REGULATORY BODY WANT TO PREVENT ACCIDENTS AND INCIDENTS. • APPLICABLE AS A TOOL OF MANAGEMENT TO HAVE PRACTICAL DAILY CONTROL OF EVENTS AND PREVENTION OF SIGNIFICANT SAFETY RELATED EVENTS.

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