Accident Investigations - Recommendations - Implementation

In any factory, after any major accident takes place leading to loss of life or huge property damage, a committee is constituted to investigate to find the root cause and secondary causes. The committee investigates and makes some recommendations. It is observed in many investigations, a number of recommendations are of general in nature, like,

i) applicable statutory requirements to be followed
ii) house keeping to be improved
iii)training to be provided
iv) supervision to be ensured
v) safety studies to be carried, etc

The management faces the problem of finding what is to be done with these types of recommendations and they are blank about how to avoid recurrence of such accidents / incidents. It appears as though a separate committee is to be constituted for each of the recommendations to understand what it means and what should be done.

Instead, if the accident investigation committee that comprises persons from production, safety, maintenance, etc is able to make recommendations specific to the factors that are responsible for the cause of accident, then the direction for management will be straight forward. For example, say that earthing and bonding is not done for all piping as per so and so legislation (Petroleum Rules). Then, this should be stated and identify the procedure and persons to be responsible for doing and checking. Similarly, a checklist can be made what should be seen for the supervisor every day for the job so that instead of simply standing to supervise the job, he will be clear of what is expected of him to ensure that the job is carried out safely. Along with these, punishments like suspension of the increment / cut in pay also should be mentioned for each of the jobs so that when a person carries the work without following the written instructions, he will face these consequences. Once every thing is put in writing right from the nature of the job, methodology, checks and punsihment, then the system is established and will become independent of the individuals. There should be no mercy for failures of the persons responsible to do the given job. Only when leniency is shown, then the parasites will grow and favouritism starts.

After the implementation of recommendations, if again a similar accidents occurs, then the committee should introspect itself about its efficiency and what went wrong. Whether all recommendations are implemented to the satisfaction / stated intention of the committee or whether full information was obtained earlier or the investigation was only a face wash and the committee should be fixed for its failure to see all facts and handed out proper punishment. After implementation of recommendations, whether all concerned employees were informed about these and whether these were trained for resumption of work is also to be seen. There can be production pressures, but if work is resumed without corrective and preventive actions, then there is no meaning in investigation. Definitely such establishements should prepare to close their shops soon.

Safety becomes an obstacle or costly affair, when proper thought is not given for it during design stage itself and then not followed. If any person says that he does not care for safety as he pays the persons through salaries, then he is a criminal and whether he will accept such a thing if his own kith and kin work in such environment should be seen. If the answer is negative, then he should not ask for output without correcting the system.