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Granskning av analysmetod för olyckor och tillbud inom tillverkningsindustrin

Sörensen, Simon LU (2015) VBR920 20151
Division of Risk Management and Societal Safety
Risk Management and Safety Engineering (M.Sc.Eng.)
Abstract
This paper aims at determine how a new accident investigation method should be designed in order to bring a more holistic view of the system of a manufacturing industry. This is especially important for an organization like Xylem, since complex systems needs methods that can handle the complexity. In order to do this the author has performed interviews and a study of accident reports from a company within the manufacturing industry. The data showed that the information obtained from the investigations were limited and the measures taken to prevent future accidents often resulted in restoring the place for the accident to its original state or taking no action at all since it did not seem possible to do so. The information was then compared... (More)
This paper aims at determine how a new accident investigation method should be designed in order to bring a more holistic view of the system of a manufacturing industry. This is especially important for an organization like Xylem, since complex systems needs methods that can handle the complexity. In order to do this the author has performed interviews and a study of accident reports from a company within the manufacturing industry. The data showed that the information obtained from the investigations were limited and the measures taken to prevent future accidents often resulted in restoring the place for the accident to its original state or taking no action at all since it did not seem possible to do so. The information was then compared to different methods for accident investigation found in the literature. This gave a number of challenges for the company regarding their safety work in preventing future accidents from occurring. These challenges were then addressed and some criteria’s for the design of a new investigation method were suggested. These criteria’s are to be used in the construction of a new method for accident investigation designed to meet the needs of the organization. The next step from this paper is to construct this method using the criteria’s determined here. (Less)
Popular Abstract
An accident can happen at any time and place. It seems to be impossible to foresee exactly what is going to happen and how. Although, we can lower the possibility or mitigate the consequence of accidents by analysing them in order to understand them. And we need proper methods to do just that.
The paper aims to find a way to analyse accidents in order to get knowledge of how to prevent future accidents from happening. In order to prevent accidents first we need to understand the different factors that contribute to them. Often it is easy to look at an accident in hindsight and find a factor that to the observe looks to be the most important one, but the reality might be another. Often there are many factors that contribute to an... (More)
An accident can happen at any time and place. It seems to be impossible to foresee exactly what is going to happen and how. Although, we can lower the possibility or mitigate the consequence of accidents by analysing them in order to understand them. And we need proper methods to do just that.
The paper aims to find a way to analyse accidents in order to get knowledge of how to prevent future accidents from happening. In order to prevent accidents first we need to understand the different factors that contribute to them. Often it is easy to look at an accident in hindsight and find a factor that to the observe looks to be the most important one, but the reality might be another. Often there are many factors that contribute to an accident. Most of them are just harder to find then the ones that just triggered the accident.
In many cases of accident investigation we look for root causes, which means the thing that started the accident and without it there would be no accident. Often a linear type of thinking makes us believe this and therefore we miss other factors that are deemed not as important. But in reality the not so important factors contribute to the accident as well.
The idea of removing a factor and believing that the accident would not have happened is not always good. An example of this is a person misreading a serial number of a tool because he or she has slightly decreased eyesight. Then we could remove that person from the task that includes reading these numbers or we could make the serial numbers more visible and easier to read for everyone. By choosing the first alternative the risk would still be there when another person with similar characteristics performing the task. If we choose the second alternative, next time an individual with poor eyesight gets this task, there is a reduced risk of the same accident happening again. So by better accident analysis there will be better measures to prevent similar events to occur again.
The paper has looked for ways to find factors that goes beyond the direct factors that are easier to find the more distant factors. The result was a list containing the most important criteria’s that needs to be included in an accident investigation method. This list was based on a case study from a manufacturing industry in Sweden where the level of detail in the investigation was examined as well as the type of corrective measure that was taken. A number of investigators and operators from the industry was interviewed to give their view of the perks and disadvantages with the model they used at the time.
In the paper there are also some comparisons of different methods that already exist. There are also some accident models that have been the starting point for these different methods. These accident models are important to be aware of since everyone, intentionally or not, does use an accident model when trying to understand an accident.
The criteria list can be used to construct a method that is tailored to the organisation that is supposed to use it. This has been found to be very important for the design of the method. If the method does not meet the needs and goals of the organisation it is of little value. (Less)
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author
Sörensen, Simon LU
supervisor
organization
course
VBR920 20151
year
type
H2 - Master's Degree (Two Years)
subject
keywords
Accident model, human error, manufacturing industry, method, investigation, incident, Accident
report number
TVRH-5009
other publication id
ISRN:LUTVDG/TVRH--5009—SE
language
Swedish
id
7451311
date added to LUP
2015-07-13 11:41:31
date last changed
2015-07-13 11:41:31
@misc{7451311,
  abstract     = {This paper aims at determine how a new accident investigation method should be designed in order to bring a more holistic view of the system of a manufacturing industry. This is especially important for an organization like Xylem, since complex systems needs methods that can handle the complexity. In order to do this the author has performed interviews and a study of accident reports from a company within the manufacturing industry. The data showed that the information obtained from the investigations were limited and the measures taken to prevent future accidents often resulted in restoring the place for the accident to its original state or taking no action at all since it did not seem possible to do so. The information was then compared to different methods for accident investigation found in the literature. This gave a number of challenges for the company regarding their safety work in preventing future accidents from occurring. These challenges were then addressed and some criteria’s for the design of a new investigation method were suggested. These criteria’s are to be used in the construction of a new method for accident investigation designed to meet the needs of the organization. The next step from this paper is to construct this method using the criteria’s determined here.},
  author       = {Sörensen, Simon},
  keyword      = {Accident model,human error,manufacturing industry,method,investigation,incident,Accident},
  language     = {swe},
  note         = {Student Paper},
  title        = {Granskning av analysmetod för olyckor och tillbud inom tillverkningsindustrin},
  year         = {2015},
}