Accident investigation process focus

Here, although understanding has been positioned as the ultimate output of the accident investigation process, it is the worker who is effectively blamed for the incident, his action becoming the focus of the investigation process. There is a segregation of responsibility for this incident the worker s violation is separated and made distinct from the shared ownership of the accident as a whole. 

Like the previous edition, the book remains focused primarily on investigating process-related incidents that present realized or potential catastrophic consequences (that is, accidents as well as near misses). However, readers will find that the methodologies, tools, and techniques described in the following chapters may also be applied when investigating other types of occurrences such as reliability, quality, and occupational health and safety incidents. 

Change analysis in accident investigation helps you to systematically analyze problems. It builds new skills and reinforces existing ones. The practical application will enable you to focus on causes rather than symptoms and aid you in becoming more perceptive to the contributing factors of an accident. It provides a step-by-step process for getting to the core of any problem. 

Joint OSHA/EPA investigations of past accidents in tolling operations include recommendations that emphasize the importance of communication between the toller and the client. The primary ways recommended to prevent recurrence of similar events focus on a joint understanding of the basic tenets of process safety elements. 

Human operator errors are not usually examined in a FMEA, but the effects of human error are indicated by the equipment failure mode. FMEAs rarely investigate damage or injury that could arise if the system or process operated successfully. Because FMEAs focus on single event failures, they are not efficient for identifying an exhaustive list of combinations of equipment failures iliat iead to accidents. 

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