1. Accident Investigation
2009
Case study
Using
ISM Code in an
Investigation
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2. Accident Investigation
The purpose of an accident investigation is to take action to prevent accidents
from recurring.
Examples of
spectacular
accidents
Piper Alpha, TWA and
Ocean Ranger
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3. Accident Investigation
It is very important to find causes of
an accident in order to prevent
bigger ones from taking place.
There are several examples of companies that have gone bankrupt as a consequence of the physical damage resulting loss of production time after a major accident.
By going through the debris after an accident we can often find traces of
what caused the event.
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4. Nuclear contamination
THREE MILE ISLAND
CASE
Nuclear contamination
Thursday 28 may 1979
USA
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5. Three Mile Island March 28, 1979
A nuclear reactor at the Three Mile Island power plant near
Harrisburg, Pa., suffers a partial core meltdown.
The FDA immediately began radiation sampling of milk, fish
and water within a 20-mile radius of the facility.
FDA officials also arranged for the shipment of potassium iodide
to protect citizens close to the plant had there been
significant environmental leakage from the damaged reactor.
The radiation that did escape from the facility was low enough
that use of the protective drug was not needed,
and no food or other products were contaminated.
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6. Three Mile Island The Accident
There was nothing unusual about the early morning of
March 28, at the Three Mile Nuclear Generating station.
The weather was cold but not unusually so.
But during routine maintenance, an automatically operated valve
in the Unit 2 reactor closed when it should not have most likely
due to either a mechanical or electrical failure.
This shut off the water supply to the system that cools down the
reactor core and prevented the steam generators from removing
heat.
Automated systems then shut down the reactor core.
That should have been the end of the accident, but it was not.
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7. Three Mile Island The Accident
A misreading by one of the engineers on duty compounded with
a series of equipment and instrument malfunctions led to
a dangerous loss of water coolant from the reactor core.
As a result, the reactor core was partially exposed, which led to
some radioactive gases escaping into the containment
section of the reactor building.
Though some of this radiation was released into the surrounding
area, no immediate deaths or injuries occurred.
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8. Three Mile Island
Control valve
- On
- 0ff
When a small valve stuck open, cooling water escaped and
the reactor core of TMI's Unit 2 began to melt.
But at the time, nobody seemed to know what was going on.
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9. Three Mile Island Nuclear plan dismantled Equipment
Control room design errors
Cooling pump failure
Consignation error (signal )
Nuclear
plan
dismantled
Error of comprehension
of the situation
Lack of training
Incorrect recognition
of the signal
Steadiness in his
decision
Personnel
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10. Three Mile Island Nuclear plan dismantled Ergonomic Human error
Equipment
Control room design errors
Cooling pump failure
10.3
Ergonomic
Consignation error (signal )
Nuclear
plan
dismantled
Error of comprehension
of the situation
Lack of training
Human error
Incorrect recognition
of the signal
6.5
Steadiness in his
decision
Personnel
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11. Three Mile Island (After)
In the following days
"If the operators had been asleep that morning
and not touched anything,
the accident would have never happened.“
Harold Denton
20 years later
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12. Collision of two trains
A human error
FLAUJAC CASE
Collision of two trains
Saturday 3 august 1985
Paris - Rodez
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13. Flaujac Accident (Theory situation)
15:10
15:20
15:30
15:40
15:50
16:00
16:10
Roc
Amadour
local train
Rodez-Brive
7924
Corail
Paris-Rodez
6153 SA
29/06 to 07/09
7921 SF SA
6151 SA
Gramat
Flaujac
Assier
Fournel
Figeac
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14. Flaujac Accident (Actual situation)
15:10
15:20
15:30
15:40
15:50
16:00
16:10
Roc
Amadour
local train
Rodez-Brive
7924
7921 SF SA
6151 SA
6153 SA
Gramat
29/06 to 07/09
Flaujac
Assier
Fournel
Corail
Paris-Rodez
Delay
Figeac
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15. Flaujac Accident Majors Causes - Train delay - No safety loops
- Error of lecture
- Diagram complexity
- Information misunderstood
- New job ( Stress )
- Procedure not followed
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16. Flaujac Accident - 32 dead persons - 2 trains destroyed Management
Train delay
Equipment
No safety loops
- 32 dead
persons
- 2 trains
destroyed
New job
( Stress )
Personnel
Information
misunderstood
Error of lecture
Methods
Diagram
complexity
Procedure
not followed
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17. Flaujac Accident As an investigator :
Majors Causes
As an investigator :
Could you related the majors factors to the accident using a causes-effect diagram.
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18. Flaujac Accident - 32 dead persons - 2 trains destroyed
Management
Equipment
No safety loops
Trains delay
8.3
- 32 dead
persons
- 2 trains
destroyed
Error of lecture
Diagram
complexity
6.3
6.4
6.4
6.5
Information
misunderstood
Procedure
not followed
New job
( Stress )
Personnel
Methods
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19. Physical Evidence Brazaville1989 170 people died
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20. Collision of two aeroplanes
TENERIFE CASE
Collision of two aeroplanes
Sunday 27 march 1977
Airport of Santa Cruz
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21. Tenerife Accident Chronology of the event 16h 59mn 10 s
PAA fly enter on the run way to take off on the west departure way.
KLM fly is on the taxiway just behind the PAA fly.
17h 02mn 08s
PAA fly enter the west departure gate.
KLM fly pass the junction point C3 of the departure gate.
17h 05mn 44s
KLM fly is at the end of departure gate ready to take off and request
the authorisation to take off from the control tower.
17h 05mn 53s
PAA pass the junction point C3.
KLM received the authorisation to take off from the control tower.
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22. Tenerife Accident Chronology of the event 17h 06mn 09 s
KLM announce to the control tower that it will take off.
17h 06mn 19s
PAA announce that he has not degage the departure gate.
Immediately the control tower ask to KLM fly to stop
the take off procedure until new information.
KLM didn't ear the message.
The control tower didn't ask confirmation of message.
17h 06mn 25s
The control tower ask to PAA fly to inform them as soon as
the departure gate will be free.
17h 06mn 30s
PAA fly confirm to the control tower the message received.
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23. Tenerife Accident Chronology of the event 17h 06mn 33s
The KLM co-pilot who understand the message inform the pilot
that “PAA didn’t leave the departure gate”.
“Yes” affirm the pilot.
17h 06mn 49s
Collision occur near the junction point C4.
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24. taken in consideration
Tenerife Accident
KLM
Take off
PAA position
Interpretation
PAA
not visible
Heavy fog
Authorisation
Interpretation
Inadequate
wording
Impatience of
the pilot
Stop order
not followed
Non respect
of feed back
procedure
Reactors
noises
Tower control
conversation not
taken in consideration
Pilot
concentration
on delay
Hierarchical
weight
Radio
Doubt on
message
Non insistence
on message
received
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25. Tenerife Accident PAA moving Didn’t take exit N° 3 Interpretation of
the tower message
Ambiguity of
the message
Exit n°4
more easy
Used of
main runway
Holidays
period
Commercial
constraints
Traffic turned
to Santa Cruz
Taxiway
obstructed
Emergency
procedure
Bomb
explosion at
Las Palmas
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26. Tenerife Accident Majors Causes - Political crisis - Abnormal traffic
- Heavy fog
- Taxiway obstructed
- Hierarchical authority
- Wrong ground exit
- 2 radio channels out of order
- Airport Lighting system failure
- Flight delay
- Change in procedure
- Order misunderstood
- Procedure not followed
- Pilot overconfident
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27. Tenerife Accident As an investigator :
Majors Causes
As an investigator :
Could you related the majors factors to the accident using a causes-effect diagram
and ISM Code.
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28. Tenerife Accident - 582 dead persons - 2 Boeing destroyed Environment
Equipment
Political
crisis
2 radio channels
out of order
10.3
Heavy fog
Taxiway
obstructed
Lighting
system failure
- 582 dead
persons
- 2 Boeing
destroyed
Abnormal
traffic
7.0
Hierarchical
authority
Wrong
ground exit
Change in
procedure
5.2
5.2
8.3
Order
misunderstood
7.0
6.4
Flight
delay
Procedure
not followed
Pilot
overconfident
Management
Personnel
Methods
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29. Ocean Ranger Tragedy (1982)
84 men died
on the Ocean Ranger off Newfoundland.
Located on the Hibernia field,
315 kilometers southeast of
St. John's on the Grand Banks, the Ocean Ranger sank in the wild winter seas in one of Canada's worst marine disasters.
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30. Ocean Ranger Testimony of the Government Inspector
- An entire roughneck (drilling) crew of four to five men had
quit over an injury to an inexperienced fellow worker. - Verbal abuse of the roughnecks by the driller was normal
Ocean Drilling and Exploration Co procedure
(The owner of the rig and in charge of its drilling crews).
Verbal abuse was one of the causes of an accident
in which a new worker on the drill floor lost two fingers
when they were caught in an elevator. - Supervisors on the Ranger and other offshore rigs seemed
to be cooperative with federal inspectors, but that there was
a widespread feeling among ordinary crew members that
they should keep quiet about problems on their vessels.
The crew often seem to feel, rightly or wrongly, that they will
lose their jobs if they give information to inspectors.
It has been twenty-two years since 84 men died on the Ocean Ranger off Newfoundland. Located on the Hibernia field, 315 kilometres southeast of St. John's on the Grand Banks, the Ocean Ranger sank in the wild winter seas in one of Canada's worst marine disasters. In testimony before the Ocean Ranger Royal Commission, on December 15, 1982, the government inspector, who was last to survey the rig before it sank, had this to say:
"An entire roughneck (drilling) crew of four to five men had quit over an injury to an inexperienced fellow worker, he said. Freeman's report said verbal abuse of the roughnecks by the driller 'was normal ODECO procedure.' Ocean Drilling and Exploration Co. was the owner of the rig and in charge of its drilling crews. Verbal abuse, Freeman alleged, was one of the causes of an accident in which a new worker on the drill floor lost two fingers when they were caught in an elevator. Freeman also testified that supervisors on the Ranger and other offshore rigs seemed to be cooperative with federal inspectors, but that there was a widespread feeling among ordinary crew members that they should keep quiet about problems on their vessels. 'The crew often seem to feel, rightly or wrongly, that they will lose their jobs if they give information to inspectors,' he said. Occasionally, they would volunteer information about the rigs, but usually with a request they not be identified, he said." (Canadian Press article)
If the Ocean Ranger workers had been unionized, they would have had an effective health and safety committee that could have ensured that they had sound health and safety education and training. If they had been unionized, they would not have been afraid to speak out to a government inspector. They might be alive today if their concerns about safety had been acted upon.
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31. Ocean Ranger Conclusion from Government Inspectors
If the Ocean Ranger workers had been unionized, they would have had an effective health and safety committee that could have ensured
that they had sound
health and safety
education and training.
If they had been unionized, they would not have been afraid to speak out
to a government inspector.
It has been twenty-two years since 84 men died on the Ocean Ranger off Newfoundland. Located on the Hibernia field, 315 kilometres southeast of St. John's on the Grand Banks, the Ocean Ranger sank in the wild winter seas in one of Canada's worst marine disasters. In testimony before the Ocean Ranger Royal Commission, on December 15, 1982, the government inspector, who was last to survey the rig before it sank, had this to say:
"An entire roughneck (drilling) crew of four to five men had quit over an injury to an inexperienced fellow worker, he said. Freeman's report said verbal abuse of the roughnecks by the driller 'was normal ODECO procedure.' Ocean Drilling and Exploration Co. was the owner of the rig and in charge of its drilling crews. Verbal abuse, Freeman alleged, was one of the causes of an accident in which a new worker on the drill floor lost two fingers when they were caught in an elevator. Freeman also testified that supervisors on the Ranger and other offshore rigs seemed to be cooperative with federal inspectors, but that there was a widespread feeling among ordinary crew members that they should keep quiet about problems on their vessels. 'The crew often seem to feel, rightly or wrongly, that they will lose their jobs if they give information to inspectors,' he said. Occasionally, they would volunteer information about the rigs, but usually with a request they not be identified, he said." (Canadian Press article)
If the Ocean Ranger workers had been unionized, they would have had an effective health and safety committee that could have ensured that they had sound health and safety education and training. If they had been unionized, they would not have been afraid to speak out to a government inspector. They might be alive today if their concerns about safety had been acted upon.
84 men died
They might be alive today if their concerns about
safety had been acted upon.
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32. PIPER ALPHA Destroyed by a fire Wednesday 6 July 1988 North Sea
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33. Piper Alpha What was Piper Alpha?
Piper Alpha was a large North Sea oil platform that started
production in 1976.
It produced oil from 24 wells.
In its early life it had also produced gas from two wells.
It was connected by an oil pipeline to Flotta and
by gas pipelines to two other installations.

34. Piper Alpha What happened ?
On 6 July 1988 there was a massive leakage of gas condensate
which was ignited causing an explosion which led to large oil fires.
The heat ruptured the riser of a gas pipeline from another installation.
This produced a further massive explosion and fireball that engulfed
the Piper Alpha platform.
All this took just 22 minutes.
The scale of the disaster was enormous.
167 people died, 62 people survived..

35. Piper Alpha What caused the leak?
It is believed that the leak came from pipe work connected to
a condensate pump.
A safety valve had been removed from this pipe work for overhaul
and maintenance.
The pump itself was undergoing maintenance work.
When the pipe work from which the safety valve had been removed
was pressurised at start-up, it is believed the leak occurred.

36. Piper Alpha Accident Supercharger Pump A Pump B
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37. Piper Alpha Chronology of the event 3 July 6h 00
The gas treatment operation is stop for a maintenance reason.
15h 30mn
The operation pass in operational mode n°1.
6 July
The pump A start to knock. The chief engineer decide to make a revision,
and switch to pump B.
A work permit is issued signed by the head of production,
the chief of safety and the shift supervisor.
A copy of the work permit stay in the operating room.
The electrical system is switch off, but the maintenance was not planned.
Two sub-contracting technicians take this opportunity to make the
maintenance operation on the security valve associate to the pump A.
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38. Piper Alpha Chronology of the event 6 July
A second work permit is issued according to the procedure.
The valve is isolated by an operator.
The technicians removed the valve and fix plugs on both side
of the open canalisation. No obligation to test the water-tightness.
The valve is bought to the maintenance shop, where the work is done.
When finish just before 6PM, the crane was not available.
The reinstallation job was postponed to the next day.
The procedure in that case was follow and a copy of the work permit
signed by the head of production, them suspended by
the safety department until next day (Why?).
This event should have been notified in the operating log book.
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39. Piper Alpha Chronology of the event 6 July 18h00 Shift change. 21h50
Failure of Pump B.
21h53
The level of liquid in the pressure reducer increased, alarm signal start.
21h54
Report in operating room “the pump B will not start”
21h56
A low gas alarm start in the sector of the centrifugal compressor
area Modules C. Two of three compressors failed.
21h57
A major gas alarm start in the sector of the centrifugal compressor.
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40. Piper Alpha Chronology of the event 6 July 21h58
First explosion. Emergency activated in operating room.
Smoke visible under the ceiling of the 68 floor.
10 to 30 seconds after the first visible flames
a second explosion happened.
21h59
Crude oil from the main pipe accede from the area of extraction.
Major damages happened in the operating room and maintenance shop.
Safety light in service failed.
22h00
Operating room notice a major drop of crude oil in the pipe.
The fire safety system didn’t worked.
Piper Alpha send “Mayday”
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41. Piper Alpha Chronology of the event 6 July 22h07
The radio leave it job because of the high temperature.
22h22
Colossal explosion. The platform intruded by a fireball and
sacked by a explosion show an inclination of 45°.
23h00
The surface of the sea is burning all around the platform.
7 July
01h00
Piper Alpha collapsed.
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42. Piper Alpha Majors Causes
- Lack of qualified supervisors ( summer holidays )
- Fire protection system failure
- Safety design error Safety design error
- Maintenance procedure inadequate
- Lighting safety system failure
- Routine
- Communication failure between shifts
- Life boats unavailable
- Non qualified assistants
- Not regular operating procedure
- Minimum manning requirements
- Work permit procedure inadequate
- Drills & exercises no formal practices
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43. Piper Alpha As an investigator :
Majors Causes
As an investigator :
Could you related the majors factors to the accident using a causes-effect diagram
and ISM Code.
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44. Maintenance procedure Communication failure
Piper Alpha
Management
Equipment
6.2
Fire protection
system failure
Safety design
error
Lack of qualified
supervisors
( summer holidays )
10.3
Life boats
unavailable
Light safety
system failure
- 167 dead
persons
- 1 platform
destroyed
- environmental
pollution
Routine
8.2
6.7
7.0
6.2
Non qualified
Not regular operating
procedure
Minimum manning
requirements
10.1
10.3
Work permit
procedure inadequate
Maintenance procedure
inadequate
Drills & exercises
no formal practices
Communication failure
between shifts
Personnel
Methods
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45. Chemical contamination
Bhopal
Chemical contamination
Sunday 2 December 1984
INDIA
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46. Bhopal Bhopal : population 800 000 600 km from Delhi Union Carbide :
- Pesticides plan
workers including sub-contractors
- Production :
1981 : 5200 tons
1982 : 2300 tons
1983 : 1650 tons
- Turn over: 15 millions $
- Estimated loss of 4 millions $ per year.
The accident started in the stock area
of the methyl isocyanate ( MIC )
That day the equipment N° 610 contained
41 tons of MIC
Delhi
Bhopal
Stainless steel
Chloroform
( Water + MIC )
= Exothermic reaction
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47. Bhopal
On the night of the 2-3 December 1984 water inadvertently entered
the MIC storage tank, where over 40 metric tons of MIC
were being stored.
The addition of water to the tank caused a runaway chemical reaction,
resulting in a rapid rise in pressure and temperature.
The heat generated by the reaction, the presence of higher than normal
concentrations of chloroform, and the presence of an iron catalyst ,
produced by the corrosion of the stainless steel tank wall,
resulted in a reaction of such momentum, that gases formed
could not be contained by safety systems.
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48. Bhopal As a result, MIC and other reaction products, in liquid and
vapour form, escaped from the plant into the surrounding areas.
There was no warning for people surrounding the plant as
the emergency sirens had been switched off.
The effect on the people living in the shanty settlements
just over the fence was immediate and devastating.
Many died in their beds, others staggered from their homes,
blinded and choking, to die in the street.
Many more died later after reaching hospitals and
emergency aid centres.
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49. Bhopal The factory was closed down after the accident.
The early acute effects were vomiting and burning sensations in the eyes,
nose and throat, and most deaths have been attributed to respiratory
failure.
For some, the toxic gas caused such massive internal secretions that
their lungs became clogged with fluids, while for others, spasmodic
constriction of the bronchial tubes led to suffocation.
It is been estimated that at least 3,000 people died as a result of
this accident, while figures for the number of people injured
currently range from 200,000 to 600,000 people,
with an estimated 500,000 typically quoted.
The factory was closed down after the accident.
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50. Bhopal The Bhopal disaster was the result of a combination of:
legal, technological,
organizational, and
human errors.
The immediate cause of the chemical reaction was the
seepage of water (500 litres) into the MIC storage tank.
The results of this reaction were exacerbated by
the failure of containment and safety measures
and by a complete absence of community information
and emergency procedures.
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51. Bhopal The long term effects were made worse by the absence of systems
to care for and compensate the victims.
Furthermore, safety standards and maintenance procedures at
the plant had been deteriorating and ignored for months.
A listing of the defects of the MIC unit runs as follows:
- Gauges measuring temperature and pressure in the various parts of
the unit, including the crucial MIC storage tanks, were so notoriously
unreliable that workers ignored early signs of trouble.
- The refrigeration unit for keeping MIC at low temperatures
(and therefore less likely to undergo overheating and expansion
should a contaminant enter the tank) had been shut off for some time.
- The gas scrubber, designed to neutralize any escaping MIC,
had been shut off for maintenance.
- Even had it been operative, post-disaster inquiries revealed,
the maximum pressure it could handle was only one-quarter
that which was actually reached in the accident.
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52. Bhopal
- The flare tower, designed to burn off MIC escaping from the scrubber,
was also turned off, waiting for replacement of a corroded piece of
pipe.
- The tower, however, was inadequately designed for its task, as it was
capable of handling only a quarter of the volume of gas released.
- The water curtain, designed to neutralize any remaining gas, was too
short to reach the top of the flare tower, from where the MIC was
billowing.
- The lack of effective warning systems; the alarm on the storage tank
failed to signal the increase in temperature on the night of the disaster.
MIC storage tank number 610 was filled beyond recommended
capacity; and the storage tank which was supposed to be held
in reserve for excess MIC already contained the MIC.
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53. Bhopal Majors Causes - Lack of qualified supervisors
- Total lack of safety culture
- Cut on maintenance programme
- Under qualified subcontractors
- No emergency plan
- Reduction of quality control personnel
- Safety rules violation
- Budget restrictions
- Lack of maintenance on safety equipment
- Lack of training
- Safety valve failure
- No plug for isolation of the system
- Lack of knowledge of the process
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54. Bhopal Consequences - More than 2 300 dead Persons - 170 000
contaminated
- Environmental
pollution
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55. Could you identify some deviations from the requirements
Bhopal
Using ISM Code :
Could you identify some deviations from the requirements
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56. Causes - Effect Diagram
Tuna
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57. Bhopal Management Methods - more than 2 300 dead persons - 170 000
contaminated
- environmental
pollution
Personnel
Equipment
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58. Management Methods 2.1 8.1 3.3 6.2 2.2 10.2 10.1 4.0 - more than
Total lack of
safety culture
2.1
8.1
3.3
6.2
No quality control
Lack of qualified
supervisors
2.2
10.2
10.1
4.0
No emergency
plan
Budget restrictions
- more than
2 300 dead
persons
contaminated
- environmental
pollution
No maintenance
programme
Safety rules
violation
Unqualified
subcontractors
6.4
6.6
6.3
Lack of maintenance
on safety equipment
Lack of training
10.2
7.0
Safety valve failure
No plug for isolation
of the system
Lack of knowlege
of the process
Personnel
Equipment
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59. Bhopal
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60. Other Accident Causation Ships in Service Training Material
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61. Other Accident Causation
Kings Cross Fire (1987) 31 died
- Discarded cigarette
- Accumulation of rubbish
- Poor housecleaning practice
- Wooden escalator
- Failure of fire fighting
equipment
- Lack of emergency training
- Poor safety culture
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62. Other Accident Causation
Herald of Free Enterprise (1987) 189 died
- Failure to close bow doors
- No checking/reporting system
- Commercial pressures
- Internal friction
- Disease of sloppiness
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63. Other Accident Causation
Clapham Junction (1988) 35 died & 500 injured
- Signal failure
- Incorrect maintenance
- Degradation of working
practices
- Training problems
- Communication problems
- Poor supervision
- Excessive working hours
- Failure to learn lessons
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64. Non respect of a procedure
Most of the
major accidents
have for origins
Error of diagnosis
Late decision
Ambiguous
communication
Misinterpretation
of a signal
Non respect of a procedure
or regulation
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65. Before Starting AN ACCIDENT INVESTIGATION IN SHIPPING INDUSTRY
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66. ? Grounding Stranding (21%) Foundered (44%) Fire Explosion (16%) Ships
lost
Contact (1%)
Collision (12%) ?
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67. ? Grounding Stranding (21%) Foundered (44%) Fire Explosion (16%) Ships
lost
Contact (1%)
Collision (12%) ?
Adverse
weather
High speed
Technical
circumstances
Stress
Social hierarchy on board
Speed
Practices
Fatigue
Poor
planning
Management deficiencies
Training
Reduction
of crew
Defective equipment
Design
Blind eyes to procedures
Lack of attention
Communication failures
Careless overconfidence
Error of judgement
Excessive speed
A - M CHAUVEL - BUREAU VERITAS

68. independent investigator ?
Why do we need an
independent investigator ?
The benefits of good accident investigation Apart from achieving the ultimate goal of preventing a recurrence of the same or similar accident, effective accident investigation can provide many benefits to an organisation, including;
 Identifying out-moded operational methods
 Improvements in the work environment
 Increased productivity due to modification of equipment and machinery
 Improvements to operational and safety procedures
 Improved safety awareness
Ships in Service Training Material
A-M CHAUVEL

69. Ghislengien Belgium July 30 2004
LNG
Pipeline Explosion

70. Ghislengien Gas explosion
in bleu :
( Declarations of the
Fluxys management )
Pipeline
Environment
Development of the industrial zone
Bad condition
Material
( meets International
standards)
Pressure
too high
Flooded risk area
Consolidation work
of the underground
(under the
standard)
Explosion :
16 dead
120 Injured
Quality control
procedures
Denied need for evacuation of the area ?
(Respected)
Gates closed only after the explosion
External
threat
Procedures
Management
Ships in Service Training Material
A-M CHAUVEL