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for CpE

Regene G. Hernandez

Instructor I
Accident Cases
– Challenger Space Shuttle Explosion
– January 28,1986
– 7 crew died
– Cause of the explosion:
– Cold conditions did not allow the O-rings of the solid rocket
booster to properly seat

– Factors that caused the accident

– Shortcomings in hazard assessment
– Failure of communication
– Pressure to achieve the launch
Accident Cases
– Chernobyl Disaster
– April 26,1986
– 30 people were killed
– 209 on site and involved with the clean-up were treated for
acute radiation poisoning
– Cause of the accident:
– Flaw reactor design
– Operation with inadequately trained personnel
Accident Cases
– The Herald of Free Enterprise
– March 6, 1987
– 197 people died
– Immediate cause of accident:
– The inner and outer bow doors had not been shut allowing
water to rapidly fill the cargo deck.
– Underlying causes:
– General instruction to close the bow doors was regularly
– There was no safe system of work
– Not my responsibility’ attitude staff
– Why some accidents are
– It is a question of design
– It is a case of negligence
– It is a question of incompetence
– The mentality of business first before
– What is an accident?
– An event that is occurring to a worker that was an
unlooked-for mishap or an untoward event, which is not
expected or designed by the victim
– An unexpected, unplanned event in a sequence of
events, that occurs through a combination of causes;
it result in physical harm (injury or disease) to an individual,
damage to property, near-miss, a loss, or any combination
of these effect.
– What is a risk?
– Anything that poses the likelihood
of harm being done from a
particular hazard
– It can be defined as a probability
that an accident will occur
– What is hazard?
– Anything that has the potential to
cause harm or Damage to people,
property, or environment.
– What safety?
– The safety in which the possibility of harm to
persons or to property damage is reduced to,
and maintained at or below, an acceptable
level through a continuing process of hazard
identification and safety risk management.
– Technological Improvement and Compliance

– The accident-prone commercial aviation

– Technical upgrades
– Following rules and regulations
– Personal Training

– Personnel not doing what

they were expected to do
and vice-versa.
– Investigating unsafe acts by
– Organizational Factors
– Emphasis to the hazardous condition or
The cause of the accident instead of the giving
Recommendations to the immediate problem
– Accident causation (The Reason Model)
– Management decisions and organizational
– Working conditions
– Errors and violations