Accident Analysis System Research Articles

Systemic accident analysis: Examining the gap between research and practice

The systems approach is arguably the dominant concept within accident analysis research. Viewing accidents as a result of uncontrolled system interactions, it forms the theoretical basis of various systemic accident analysis (SAA) models and methods. Despite the proposed benefits of SAA, such as an improved description of accident causation, evidence within the scientific literature suggests that these techniques are not being used in practice and that a research–practice gap exists. The aim of this study was to explore the issues stemming from research and practice which could hinder the awareness, adoption and usage of SAA. To achieve this, semi-structured interviews were conducted with 42 safety experts from ten countries and a variety of industries, including rail, aviation and maritime. This study suggests that the research–practice gap should be closed and efforts to bridge the gap should focus on ensuring that systemic methods meet the needs of practitioners and improving the communication of SAA research.

Wireless In-Vehicle Compliant Black Box: For Accident Analysis

In this article, a novel accident analysis system is proposed to determine the main human factors involved in traffic accidents. Several tests of the system were carried out in a highly realistic truck simulator with a group of professional drivers. The data, collected with the system at the moments before traffic accidents, were used to generate a novel database that was carefully analyzed by a group of traffic safety experts. The validation process shows the reliability of the developed system as a tool for the identification of the main cause of traffic accidents.

Overcoming the blame game to learn from major accidents: A systemic analysis of an Anhydrous Ammonia leakage accident

This article aims to demonstrate the need for changing the methods with which accidents are analyzed, if we truly wish to use what we uncover from them to learn and enrich our knowledge base of organizational management. The goal is to relinquish the broadly adopted and rather simplistic paradigm that accepts the search for human error and unsafe acts performed by workers, and produces “guilt diagnostics”. Instead, we use a systemic accident analysis methodology, based on the sociotechnical principle of understanding the real operating conditions in which accidents take place. In order to demonstrate the benefits of the theoretical framework, we compare the analyses of an Anhydrous Ammonia gas leakage accident in a fish processing plant using the traditional accident analysis model based on unsafe acts and the proposed systemic approach. The results favor the latter since it tends to be more reliable and offering useful recommendations to safety management processes, thus helping to prevent accidents, especially in complex systems.

EFFECTS OF ROAD GEOMETRY AND SEASON ON HEAD-ON AND SINGLE-VEHICLE COLLISIONS ON RURAL TWO LANE ROADS IN HOKKAIDO, JAPAN

This study investigates the road geometry factors and the seasonal factors associated with head-on collisions and single vehicle collisions occurred in Hokkaido, Japan. Head-on collisions represent about 20% of all traffic collisions on the rural two lane national roads however; head-on collisions were responsible for about 40% of the fatal collisions. We developed a segmented accident database based on Traffic Accident Analysis System (TAAS) produced by Civil Engineering Research Institute for Cold Region Hokkaido. Analysis using Poisson-regression models showed that road geometry factors and seasonal factors were important factors correlated with head-on collisions. The model proposed in this study is potentially capable of identifying the causal factors of head-on and single vehicle collisions. In addition, the model might be used as the safety evaluation function in the development of the before-after study.

Geographical information systems aided traffic accident analysis system case study: city of Afyonkarahisar

Geographical Information System (GIS) technology has been a popular tool for visualization of accident data and analysis of hot spots in highways. Many traffic agencies have been using GIS for accident analysis. Accident analysis studies aim at the identification of high rate accident locations and safety deficient areas on the highways. So, traffic officials can implement precautionary measures and provisions for traffic safety. Since accident reports are prepared in textual format in Turkey, this situation makes it difficult to analyze accident results. In our study, we developed a system transforming these textual data to tabular form and then this tabular data were georeferenced onto the highways. Then, the hot spots in the highways in Afyonkarahisar administrative border were explored and determined with two different methods of Kernel Density analysis and repeatability analysis. Subsequently, accident conditions at these hot spots were examined. We realized that the hot spots determined with two methods reflect really problematic places such as cross roads, junction points etc. Many of previous studies introduced GIS only as a visualization tool for accident locations. The importance of this study was to use GIS as a management system for accident analysis and determination of hot spots in Turkey with statistical analysis methods.

Streamlining Chinese Highway Accident Data Acquisition, Communications, and Analysis

This research examines a streamlined accident data acquisition, communications, and analysis system to improve the Chinese highway safety program. A data logger compatible with the Global Positioning System and geographic information system is proposed to identify highway accident locations and organize the data into a database format. A data encoding concept is used to transform Chinese characters into numbers, so that the encoded data are easy to integrate into a large data system. A three-tier client–server networking system is set up as the backbone framework for data communications between the central database and distributed local offices. Using local database functions, traffic police at the client level can view crash data through data mapping and attribute listing and analyze the data through nested query and sorting operations. A data graphing and analysis module was tested for automatically constructing a collision diagram on selected data. The proposed approach to crash data acquisition and analysis was found to be feasible and effective and will help to enhance China’s highway safety program after full implementation.

Systemic accident analysis of deaths due to failed Björk-Shiley heart valves

The Björk-Shiley convexo-concave artificial heart valve has a significant risk of failure which is often fatal.Elective explantation has a mortality of approximately 5%. Follow-up studies provide the basis for clinical decision making whether or not to explant the valve. So far, the contribution of technical, organizational, ethical, and professional considerations to success or failure of any risk control strategy have hardly been considered. A string of six consecutive deaths due to valve failure initiated a systemic rather than an epidemiological analysis of the problem. Systemic failure analysis not only yields sound explanations, but also warrants acceptable solutions on the basis of assembling multidisciplinary knowledge and experience.

Évaluation de la qualité des soins en anesthésie

Quality assessment (assurance/improvement) is the set of methods used to measure and improve the delivered care and the department's performance against pre-established criteria or standards. The four stages of the self-maintained quality assessment cycle are: problem identification, problem analysis, problem correction and evaluation of corrective actions. Quality assessment is a measurable entity for which it is necessary to define and calibrate measurement parameters (indicators) from available data gathered from the hospital anaesthesia environment. Problem identification comes from the accumulation of indicators. There are four types of quality indicators: structure, process, outcome and sentinel indicators. The latter signal a quality defect, are independent of outcomes, are easier to analyse by statistical methods and closely related to processes and main targets of quality improvement. The three types of methods to analyse the problems (indicators) are: peer review, quantitative methods and risks management techniques. Peer review is performed by qualified anaesthesiologists. To improve its validity, the review process should be explicited and conclusions based on standards of practice and literature references. The quantitative methods are statistical analyses applied to the collected data and presented in a graphic format (histogram, Pareto diagram, control charts). The risks management techniques include: a) critical incident analysis establishing an objective relationship between a 'critical' event and the associated human behaviours; b) system accident analysis, based on the fact that accidents continue to occur despite safety systems and sophisticated technologies, checks of all the process components leading to the impredictable outcome and not just the human factors; c) cause-effect diagrams facilitate the problem analysis in reducing its causes to four fundamental components (persons, regulations, equipment, process). Definition and implementation of corrective measures, based on the findings of the two previous stages, are the third step of the evaluation cycle. The Hawthorne effect is an outcome improvement, before the implementation of any corrective actions. Verification of the implemented actions is the final and mandatory step closing the evaluation cycle.

Validation of Neutronic Codes for Distorted Core Configurations with the SNEAK-12 Critical Assemblies

The reactivity effect sof material rearrangements, simulating conditions in a postulated liquid-metal fast breeder reactor accident, were measured in three different critical assemblies: SNEAK-12A, a single-zone core, fueled with enriched uranium metal plates; SNEAK-12B, which had a central test zone fueled with PuO/sub 2/O/sub 2/ rod bundles surrounded by a buffer and a driver zone; and SNEAK-12C, which had nearly the same integral compositions as SNEAK-12B but was loaded totally with plates. The reactivity effects were calculated using current Kernforschungszentrum Karlsruhe methods and data and, in part, also using the corresponding modules of the SIMMER-II accident analysis system. Also, for some configurations, a comparison of measured and calculated fission rate distributions was performed. The evaluation yielded similar results for the three assemblies. For most cases investigated, satisfactory agreement between theory and experiment was reached when two-dimensional transport eigenvalue calculations or exact transport perturbation methods were used. As long as larger deviations occurred, transport results generally were on the conservative side. First-order transport perturbation theory only worked well in a limited number of cases. Diffusion calculations often led to large discrepancies, particularly when the experiments involved fuel dilution.

Scenario Analysis of Petrochemical Worker Injuries

More traditional approaches to accident reporting and analysis have received much critisism in recent years. The dispute apparently lies in their inability to facilitate intervention development due to a primary non-ergonomic orientation as well as limited suitability as an information management system. Laughery, Petree, Schmidt, Schwartz, Walsh and Imig (1983) in an effort to address these issues adopted the human factors based scenario and analytic technique developed by Drury and Brill (1983) and devised a accident coding and analysis system. In an study of 1,694 operator cases taken over a three year period at a petrochemical facility in the Houston, TX area, five separate accident patterns accounting for 80% of all the reported cases were found. The scenarios are as follows: 1) muscular/skeletal strain in system operation. 2) chemical release due to system breakdown. 3) obstruction in the workspace. 4) unsolicited interface movement during system operation. 5) poor footing in the workspace. A closer analysis of each scenario revealed apparent design flaws and managerial policy problems, that if corrected would reduce incident numbers significantly.

Measurements and Computation of the Reactivity Effects of Accident-Caused Core Distortions in Liquid-Metal Fast Breeder Reactors

The reactivity effects of material rearrangements, simulating conditions in a postulated liquid-metal fast breeder reactor accident, were measured in SNEAK-12A, a single-zone uranium fueled critical assembly, and calculated using current Kernforschungszentrum Karlsruhe methods and data and, in part, also using the corresponding modules of the SIMMER-II accident analysis system. For all cases investigated, satisfactory agreement between theory and experiment was reached when two-dimensional transport eigenvalue calculations were used. The application of first-order perturbation theory or diffusion theory in a number of cases led to larger discrepancies, particularly when the experiments involved fuel compaction.