Accident/incident analysis basic causes

For the analysis of accidents and incidents in aviation, roughly two streams can be distinguished in the literature, namely accident analysis and risk analysis. Whilst the former has the goal to determine the cause of an accident that actually took place, the latter aims to assess the likelihood of the occurrence of future accidents. Hence, although both streams have similar purposes, a main difference is that accident analysis attempts to identify one specific combination of hazardous factors, whereas risk analysis basically explores a whole range of such factors, and the associated risks. Nevertheless, most of the existing approaches are used for both streams. 

A root cause analysis is not a search for the obvious but an in-depth look at the basic or underlying causes of occupational accidents or incidents. The basic reason for investigating and reporting the causes of occurrences is to enable the identification of corrective actions adequate to prevent recurrence and thereby protect the health and safety of the public, the workers, and the environment. Every root cause investigation and reporting process should include five phases. While there may be some overlap between phases, every effort should be made to keep them separate and distinct. The phases of a root cause analysis are ... 

The chance of an incident is generally a function of the distance traveled. Thus, the frequency of an accident is often expressed as an accident rate per mile. Contributions from non-accident-initiated events are typically expressed on a frequency-per-hour or per-year basis. Thus, the duration of the hazardous materials movement is a key parameter. Figure 5.3 illustrates the basic calculation sequence for one trip or movement. If multiple trips are made, the total risk is equal to the number of trips times the risk per trip. The basic calculation sequence will have minor variations for each mode of transport and can be broken down into greater detail as needed. Increased detail might include different accident rates and lengths for each segment of a route or might explicitly address the accident rates and release probabilities for different accident causes. Inputs to the analysis that may be altered or may influence the calculation include ... 

Literature has many theories and concepts discussing human reliability and associated human error causal factors that always trigger incidents and accidents within safety-critical systems. The main - by definition - characteristics of such safety occurrences are their randonmess, rare predictability, sophisticated, yet vague sequence of propagation. Such characteristics can basically allow for the retrospective analysis of these occurrences and their causes at various sectors and levels within industry such that re-occurrence margins are reduced if not totally eliminated. The major drawback of such reactive treatment... 

A root cause analysis is not a search for the obvious but an in-depth look at the basic or underlying canses of occnpational accidents or incidents. The following should be considered when performing analyses ... 

Fig. H/3.2.5 1 is an important record-keeping document for HAZID analysis. This hazard register is same as the risk register discussed in Clause 3.2 of Chapter I, and details of the risk register are shown in Fig. 1/3.2.1-1. Since details of the risk register are already available, it will not be repeated here. Fig. 11/3.2.5-1 shows the basic structure. In the case of HAZID, hazard register is the popular term, hence it is used here. These hazard registers are available for each section of the facility. For each section, all hazards and major incidents/accidents are listed along with the probable cause. The register also contains the control measure, assumptions, etc. This will become the main document for subsequent use.

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