Accident causation analysis

This is accomplished using the ECFC and the Critical Human Achon Profile (CHAP), a fask analysis-based method used to identify the most critical actions necessary for the performance of the task. Change Analysis is a technique for investigating the role of change in accident causation. It will be described in Section 6.8.6. 

The Swiss cheese model of accident causation was originally proposed by British psychologist James T. Reason and has since gained widespread acceptance in many risk-analysis and management fields including process safety. 

According to the modem accident-causation (G. and B. et al., 2005), from the point of individual behavior-safety control, hazard is embodied unsafe act (behavior) and unsafe condition meanwhile, under certain situation, unsafe act (behavior) can transform and result in unsafe condition. The unsafe act and unsafe condition is the direct cause of accident, deeper analysis comes to the indirect (common) cause, which include three elements inadequate safety knowledge, inadequate safety awareness, and inadequate safety habit. 

Behavior-based accident causation 2-4 model is an accident causation chain based on the analysis of the unsafe act of accident trigger. Among direct causes of accidents, the identification of unsafe act is grounded on the common direct cause of classical Heinrich s accident causation chain, modem accident causation chain (like the accident causation chain proposed by Bird and Loftus), existed con-... 

Then the analysis of unsafe act in this accident will be conducted according to behavior-based accident causation 2-4 model. 

The goal of STAMP is to assist in understanding why accidents occur and to use that understanding to create new and better ways to prevent losses. This chapter and several of the appendices provide examples of how STAMP can be used to analyze and understand accident causation. The particular examples were selected to demonstrate the applicability of STAMP to very different types of systems and industries. A process, called CAST (Causal Analysis based on STAMP) is described in chapter 11 to assist in performing the analysis. 

MORT Safety Assurance Systems by WilMam G. Johnson This text serves well both for incident causation model building and for incident investigation. The accident investigation chapter states that while accident investigation has always been a major element in safety, pre-accident hazard analysis is preferable (p. 347). 

Emerging concepts of system analysis, accident causation, human factors, error reduction, and measurement of safety performance strongly suggest the practicality of developing a higher order of control over hazards (than currently exists). 

The study of patient safety is the study of complexity. The study of complexity invites us to understand key concepts that can be applied to patient safety. Basic concepts from the fleld of patient safety are sharp and blunt end active and latent failure the Swiss Cheese Model of Accident Causation slips, lapses, and mistakes and hindsight bias and the fundamental attribution error. Key concepts from organizational analysis, such as normalization of deviance, diffusion of responsibility, tightly coupled work processes, and sensemaking, introduce practical lessons from high-reliability organizations. Application of specific lessons to health care are explored in Chapter Five. 

It is possible to take atty of the accident causation factors and break them down further in order to closer examine the influence that particular factor is having on the work system. This second tier analysis further increases knowledge about the work system through developing a better understanding of the individual processes that make up the system. It is in this area of investigation and analysis where we come closest to discovering tme accident causation. 

Chapter 5 is devoted to safety in offshore oil and gas industry. Some of the topics covered in this chapter are offshore industrial sector risk picture, offshore worker situation awareness concept, offshore industry accident reporting approach, and offshore industry accidents case studies. Chapter 6 is devoted to case studies of oil tanker spill-related accidents, oil tanker spill analysis, and oil spill causes. Chapter 7 presents various important aspects of human factors contribution to accidents in the oil and gas industry and fatalities in the industry. Some of the topics covered in this chapter are human factors that affect safety in general, categorization of accident-related human factors in the industrial sector, categories of human factors accident causation in the oil industry, and recommendations to reduce fatal oil and gas industry incidents. Chapter 8 is devoted to case studies of maintenance influence on major accidents in the oil and gas industry and safety-instrumented systems and their spurious activation in the oil and gas industry. 

Research has also shown that decision-makers apply shorthand methods or rules derived from earlier experiences in the analysis of causes of accidents. For instance, many decision-makers have developed rules implying that unsafe behaviour on the part of the workers is the important feature of accident causation. A decision-maker may thus stop looking for more evidence after detecting a human error, even if more important causal factors are at hand. 

Both the integrative model by Smillie Ayoub (1975) and the deviation concept by Kjellen (1984a) connect the general systems theory to the sequencing and energy models of accident causation. They encompass technical, organizational and human components of the system. Various methods of system safety analysis (e.g. fault tree analysis, incidental factor analysis) support the identification of technical and human deviations as well as the analysis of the conditions and consequences of these deviations. From the discussion of near misses and conflicts it became clear that frameworks of accident causation should cover all kinds of incidents, thus becoming frameworks of incidents. 

Incident causation is assumed to progress from the bottom to the top, which means that chances for early prevention of accidents decrease as you get closer to the top. The order of incident analysis is assumed to be top-down, but with different starting points in the iceberg depending On the type (or level) of data that trigger the detection in the first place. It is also assumed that modem investigation techniques will always try to get as far to the bottom of... 

Chua, D.K.H. and Goh, Y.M. (2004) Utilising the modified loss causation model for the codification and analysis of accident data. In S. Rowlinson (ed.). Construction Safety Management Systems, pp. 443-63. Spon Press, London. 

This chapter delves into the causation of the loss of a US. Army Black Hawk helicopter and all its occupants from friendly fire by a US. Air Force F-15 over northern Iraq in 1994. This example was chosen because the controversy and multiple viewpoints and books about the shootdown provide the information necessary to create most of the STAMP analysis. Accident reports often leave out important causal information (as did the official accident report in this case). Because of the nature of the accident, most of the focus is on operations. Appendix B presents an example of an accident where engineering development plays an important role. Social issues involving public health are the focus of the accident analysis in appendix C. 

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