Accident Process Research Articles

Quality indicators and specifications for strategic and support processes in laboratory medicine

This work is the second part of a study regarding indicators and quality specifications for the non-analytical processes in laboratory medicine. Five primary care and five hospital laboratories agreed on the indicators for two strategic processes (quality planning and project development) and various support processes (client relationships, instrument and infrastructure maintenance, safety and risk prevention, purchases and storage, personnel training). In the majority of cases, the median values recorded over 1 year is considered to be the state-of-the-art in our setting and proposed as the quality specification for the indicators stated. Values have been stratified according to primary care and hospital laboratory for referred tests and group of personnel for training. In some cases, the specifications have been set equal to zero events, such as serious incidents in the infrastructure maintenance process and number of work accidents in the safety and risk prevention process. In light of this study, an effort is needed to optimize decisions regarding corrective actions and to move from a subjective individual criterion to systematic and comparative management. This preliminary study provides a comprehensive vision of a subject that could motivate further research and advances in the quality of laboratory services.

MATHEMATICAL MODELING OF TRANSIENT EMERGENCY ELECTROMAGNETIC PROCESSES IN THE SYSTEM OF ELECTRIC TRACTION OF DC

The article deals with the description of the mathematical model the system traction electric power supply without loading in the short circuit condition and the result of the reserches this accident process. The transition quantity has been defined, and character their change too, which can use for the determined accidents processes.

Back injuries among nurses – A comparison of the accident processes after a 10-year follow-up

A prospective dynamic-population-based study was conducted to investigate whether factors involved in the accident process preceding over-exertion back injuries among nursing personnel had changed compared with 10 years earlier. The study covers all reported occupational over-exertion back injuries due to accident among nurses in the hospitals of Stockholm County during the years 1992–1993 and 2002–2003. The assumption was that several factors and events interact in the accident process causing a back injury. Detailed information about the accident process was obtained for each injury by interviews with the injured person. During the two study periods, interviews were conducted with 130 and 132 nurses, respectively. In both studies, most accidents occurred during ordinary planned patient transfers, and the distributions of the type of patient transfer were very similar. Mostly, draw sheets and walking belts were used as transfer equipment, although in about half of the cases, the patients had both physical and psychological limitations, which restricted their cooperation in the transfer. In 2002–2003, the nurses were older and had longer experience of the specific task they were doing; fewer had been given instructions on how to perform the specific task; they were more stressed and rated their RPE higher compared with nurses in 1992–1993. In 2002–2003, the injury more often led to sick leave and to longer sick leave; furthermore, the nurses more often sought medical care and more often took analgesics compared with 10 years earlier. There were no relation between age and if the injury led to a sick-leave or not or the length of sick-leave.

The Chernobyl Nuclear Catastrophe: Unacknowledged Health Detriment

The Chernobyl Nuclear Catastrophe: Unacknowledged Health Detriment

Safety analysis of beyond design basis accidents in RBMK-1500 reactors

At present the design basis accidents for RBMK-1500 are rather thoroughly investigated. The performed analyses helped to develop and implement a number of safety modifications. Further plant safety enhancement requires developing emergency procedures that would enable beyond design basis accidents management by preventing core damage or mitigating consequences of severe accidents. This paper presents results of Ignalina NPP Level 1 and Level 2 probabilistic safety assessment and their use for development of beyond design basis accidents list. The most important phenomena for RBMK type reactor severe accident management are described. The paper also presents physical processes that occur in an overheated reactor core and discusses its cooling capabilities. The discussion also includes processes that occur in the reactor and primary circuit surrounding compartments, i.e. confinement. A number of recommendations on accident processes management are presented.

Preliminary thermal-hydraulic phenomena investigation during total instantaneous blockage accident for CEFR

The Chinese Experimental Fast Reactor (CEFR) is under installation and commissioning right now. It is essential to investigate core disruptive accidents (CDAs) for the evaluation of CEFR's safety characteristic. As part-I preliminary investigation, accident of total instantaneous blockage (TIB) in single subassembly scale is modeled and analyzed. The degradation scenario has been calculated by a fluid-dynamics analysis code for liquid–metal fast reactors (LMFRs). For further investigation of accident process and influence to the neighboring bundles, seven subassembly domain is then simulated and calculated as part-II investigation. Total instantaneous blockage is assumed to occur in the center subassembly under normal operating conditions and consequences to neighboring assemblies are studied. The result shows that the key events, such as sodium boiling, clad melting, fuel particles relocation, hexcan melt-through and melt propagation into neighboring six assemblies symmetrically are adequately simulated. From comparison and discussion of the CEFR's results with the SCARABEE tests and Superphenix (SPX1)-type reactor simulation, it is concluded that all the key events appear in the same sequence whereas the propagation is limited in neighboring six assemblies. The discrepancy is probably due to less fuel inventory and better cooling capacity in CEFR subassembly design. TIB calculations help to give a better understanding and prediction of hypothetical accident scenario in subassembly blockage accidents for CEFR.

Analyses of severe accident scenarios in RBMK-1500

Abstract Even though research of severe accidents in light water reactors is performed around the world for several decades many questions remain. Research is mostly performed for vessel-type reactors. RBMK is a channel type light water reactor, which differs from the vessel-type reactors in several aspects. These differences impose some specifics in the accident phenomena and processes that occur during severe accidents. Severe accident research for RBMK reactors is taking first steps and very little information is available in the open literature. The existing severe accident analysis codes are developed for vessel-type reactors and their application to the analysis of accidents in RBMK is not straightforward. This paper presents the results of an analysis of large loss-of-coolant accident scenarios with loss of coolant injection to the core of RBMK-1500. The analysis performed considers processes in the reactor core, in the reactor cooling system and in the confinement until the fuel melting started. This paper does not aim to answer all the questions regarding severe accidents in RBMK but rather to start a discussion, identify the expected timing of the key phenomena.

06/01625 Numerical and experimental simulation of accident processes using KMS large-scale test facility under the program of training university students for nuclear power industry: Aniskevich, Y. N. and Zasukha, V. K. International Journal of Nuclear Knowledge Management, 2005, 1, (4), 300–307

06/01625 Numerical and experimental simulation of accident processes using KMS large-scale test facility under the program of training university students for nuclear power industry: Aniskevich, Y. N. and Zasukha, V. K. International Journal of Nuclear Knowledge Management, 2005, 1, (4), 300–307

Can We Predict Occupational Accident Frequency?

A model has been developed to predict the frequency and associated costs of occupational accidents in the offshore oil and gas industry. Model inputs include (1) direct factors such as quality of personal protective equipment, (2) corporate factors such as training programme effectiveness, and (3) external factors such as royalty regime. Model development was based on a review of related literature, expert opinion, and reliability analysis concepts. The model accounts for the differing relative importance of influencing factors, using quantitative data derived from a survey of safety experts. The influences of external elements on corporate actions and of corporate actions on the direct accident process are also included in a quantitative manner, again benefiting from the expert opinion survey. An introduction to the problem is provided, followed by a brief summary of the literature reviewed, a description of the model and example runs demonstrating the model's versatility and capability. Taking a broader perspective, the work offers an example of quantifying something which, at first, seems unquantifiable. Tools such as this offer valuable aids to management and provide an improvement on qualitative opinion, hunches and similar.

Probabilistic approach to risk analysis of chemical spills at sea

Risk analysis of chemical spills at sea and their consequences for sea environment are discussed. Mutual interactions between the process of the sea accident initiating events, the process of the sea environment threats, and the process of the sea environment degradation are investigated. To describe these three particular processes, the separate semi-Markov models are built. Furthermore, these models are jointed into one general model of these processes interactions. Moreover, some comments on the method for statistical identification of the considered models are proposed.

Occupational accident models—Where have we been and where are we going?

Oil and gas accident statistics reveal that workers’ potential for injury or death from occupational accidents is at least as high as that associated with explosions, fires, and other major incidents. The authors’ contribution to the ongoing efforts to improve the situation is a holistic, quantitative model capable of predicting occupational accident frequency. Model inputs include external, corporate and direct factors, and the approach includes methods often favoured by professionals from the safety, engineering, and psychology disciplines. As a precursor to model development, a comprehensive literature review was conducted. One objective of the review was to understand the previous approaches taken by other researchers and thereby identify any gaps in the knowledge. The lack of a holistic, quantitative model addressing occupational accidents in the oil and gas industry was established. A second objective was to select and categorise the factors most influential in the accident process and thereby provide a foundation for the present model. Optimal choices required a systematic study of the factors proposed by other researchers. The literature studied has been summarised in this paper, subdivided into two primary groups: (i) descriptions of existing accident models, and (ii) analyses of existing data. In addition, descriptions of literature specifically concerned with two key elements in the occupational accident process, human factors and safety culture, have been included. Based on the literature reviewed, the novelty of the present model has been discussed. The systematic approach taken to choose the factors thought most influential in the occupational accident process, and which were therefore included in the model, has been described. Some details of the proposed model have been included.

The indirect involvement of buses in traffic accident processes

The involvement of buses in accidents usually is assessed implicitly on the basis of the direct involvement of the bus in the collision or in injury production. This paper deals with the scope and forms of indirect involvement of buses (as a sight obstruction, for example). Accidents were selected by identifying the presence of the term ‘bus’ or synonyms in the text parts of complete police reports (testimonies, statements by the persons involved, etc.) available in electronic form, then analysed in detail. Direct or indirect involvement of a bus is found in 3.6% of traffic injury accidents reported by the police in the community studied (direct involvement: 1.4%; indirect involvement: 2.2%). The different forms of indirect involvement are then described, and some possibilities of preventive measures are discussed.

Numerical and experimental simulation of accident processes using KMS large-scale test facility under the program of training university students for nuclear power industry

The KMS large-scale test facility is being constructed at NITI site and designed to model accident processes in VVER reactor plants and provide experimental data for safety analysis of both existing and future NPPs. The KMS phase I is at the completion stage. This is a containment model of 2000 m3 volume intended for experimentally simulating heat and mass transfers of steam-gas mixtures and aerosols inside containment. The KMS phase II will incorporate a reactor model (1:27 scale) and be used for analysing a number of events including primary and secondary LOCA. The KMS program for background training of university students in the nuclear field will include preparation and conduction of experiments, analysis of experiment data. The KMS program for background training of university students in nuclear will include: participation in the development and application of experiment procedures, preparation and carrying out experiments; carrying out pretest and post-test calculations with different computer codes; on-the-job training as operators of experiment scenarios; training of specialists in measurement and information acquisition technologies.

Accidents in Perspective

SummaryThe paper briefly reviews past accident research, particularly pointing out two areas which have bred misconceptions: accident proneness and unicausality. It puts forward a model of the accident process which could provide a more fruitful basis for future work as well as an explanation of past research results.

Systemic analysis of so-called ‘accidents on the level’ in a multi trade company

Slips, trips and falls on the level are considered commonplace and are rarely subjected to in-depth analysis. They occur in highly varied circumstances in an occupational situation. In-depth analysis of these accidents was conducted within a company with the aim of understanding them better, to be able to discuss prevention field possibilities and priorities for the company concerned. Firstly, available data on ‘accidents on the level’ occurring over the last 4 years were analysed and a typology for these accidents was derived, based on individual activity at the time of the accident and accident location. The three most serious accident-causing situations were analysed in-depth from interviews with injured persons, as well as from activity observation and activity-related verbal information obtained from operatives. These most serious situations involved accidents occurring when climbing down from trucks or when walking either in surroundings outside company premises or from (to) a vehicle to (from) a work location. In-depth accident analysis and characterization of accident-causing situations as a whole enhance our understanding of the accident process and allow us to envisage priorities for action in the prevention field, in operational terms. Each accident-causing situation reveals environmental factors that in fact constitute accident factors (obstacle, stone, etc.), when the individual walks or climbs down from a truck. Analysis shows that other events are necessary for accident occurrence. For example, the individual may be subjected to a time constraint or may be preoccupied. Results obtained here, in a company integrating different trades, are discussed and compared with those referred to in the literature. Generalization of some of these results is also considered.

Modeling crash-flow-density and crash-flow-V/C ratio relationships for rural and urban freeway segments

There has been considerable research conducted in recent years into establishing relationships between crashes and various traffic flow characteristics for freeway segments. Most of the research has focused on determining the relationship between crashes and highway traffic volumes, while little attention has been focused on the relationships of vehicle density, level of service (LOS), vehicle occupancy, V/C ratio and speed distribution. Despite overall progress, there is still no clear understanding about the effects of different traffic flow characteristics on safety. In fact, several studies reviewed in this work were found to have methodological limitations. These include using predictive models with a normal error structure, aggregated crash rates, and inadequate functional forms for the data at hand. The original research on which this paper is based is aimed to determine the statistical relationship using commonly applied predictive models (i.e., functional forms) between crashes and hourly traffic flow characteristics, such as traffic volume, vehicle density and V/C ratios, for rural and urban freeway segments respectively. To accomplish this objective, predictive models have been developed from data collected on freeway segments located in downtown and outside of Montreal, Quebec. Three different functional forms are evaluated. The results show that predictive models that use traffic volume as the only explanatory variable may not adequately characterize the accident process on freeway segments. Functional forms that incorporate density and V/C ratio offer a richer description of crashes occurring on these facilities, whether they are located in a rural or urban environment. Finally, separate predictive models for single- and multi-vehicle crashes should be developed rather than one common model for all crash types.

Using Fault Trees and Cognitive Work Analysis to Assess Human Actions in Aviation Accidents

One of the functions of the National Transportation Safety Board (NTSB) is to examine and assess accident investigation methods and techniques. In this paper we present an approach being explored to assess human actions in aviation accidents that draws from fault tree analysis and cognitive work analysis. The paper shows how these two different approaches can be used to model human actions in an aviation accident, and then integrate the results of that process into an overall accident investigation process. The paper begins by showing how a fault tree depicts the sources of human interaction failures with aircraft systems, and then proceeds to describe the steps taken to derive the failures using cognitive work analysis. The paper concludes with a discussion of ongoing efforts to test the method and to explore other techniques.

海難船舶に関する自己完結性の定量評価法と20世紀後半における時系列解析結果による今日的特徴

It is the most important special characteristic that ships all have to hold the ability to complete their navigations by themselves, and it is defined as "the self-completion ability" in this paper. The purposes of this paper are to investigate the values of varying quantities of ship's self-completion ability on the marine traffic accidents in Japan, and for a premise, to introduce the new function for rating this ability. The new function is composed of the transition ratio from the lower level damage or risk to the higher, and the levels are arranged in a series on the process of traffic accident. The numerical values of this ability are obtained by the statistical data of all the casualties and the marine accidents requiring rescue in the latter half of the twentieth century in Japan. In consequence of these numerical results, this paper points out the average of the self-completion ability at the low level risk is improving after the 1970's but the ability at the higher is not very much change during the past about 50 years, and therefore, it is necessary to improve the ability obstructing transition to the higher level risk.

The accident process preceding back injuries among Australian nurses

A prospective dynamic-population-based study was conducted to investigate factors involved in the accident process preceding over-exertion back injuries among nursing personnel. All reported occupational over-exertion back injuries due to accidents among nurses in hospitals included in one network in Melbourne during 13 months were investigated. The assumption was that several factors interact in the accident process causing a back injury, and therefore detailed information was obtained for each injury by interviews with the injured person. Risks in the physical environment were identified using an ergonomic checklist. During the study period 127 nurses who had reported accidents leading to over-exertion back injury were interviewed. Cluster analysis yielded five well-defined clusters and their pattern of contributing factors for the accident process. The most frequent over-exertion back injury occurred during patient transfer in the bed or to/from the bed. Transfer devices were rarely used, most often due to lack of devices. Risks in the environment, most often lack of space, and/or lack of transfer devices often compelled the nurse to work in an awkward position. The nurse often felt rushed/stressed. The clusters showed the complexity of these kinds of accidents, and indicated that the measures for prevention must be of different kinds and at several different levels in the organization.

α-Particle track investigation of the Chernobyl Nuclear Power Plant accident region soil samples

Results of α-particle track studies (Radiat. Meas. 25(1–4) (1995) 413; Radionuclides and Heavy metals in Environment, Vol. 5, 2001, Kluwer Academic Publisher, Dordrecht) indicate that the surface (⩽5 cm) layer of the soil in the Chernobyl Nuclear Power Plant (NPP) accident region consists of thinly dispersed radionuclides and highly-radioactive “hot” particles (HPs). The latter contain nearly 2/3rds of the total α-activity of the contaminated soil. In the present report, the new results of continued HP α-activity characteristics are presented. The chief attempt made was to investigate size–frequency vs. α-activity distribution of HPs of size fraction ⩽10– 100 μm . For the Hp-aggregates with ∼100– 1000 μm sizes, α-radio-nuclide heterogeneity was established. This is probably the result of formation of HP-aggregates during the second stage of the NPP accident process: in these HPs the presence of not only U and fission products of “fuel” origin has been revealed, but also of terrestrial matter components.