Accidents change 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. 

Change may be the mother of progress but it is really the mother of twins progress and trouble. The consequences of change should always be considered carefully. Many accidents are caused because the results of changes are not anticipated. The procedure for change analysis is ... 

During the operations phase, new hazards are identified by periodic inspections, worksite monitoring, audits, and appraisals. Techniques used to identify hazards during the operations phase include checklists, PET analysis, and safety studies. Accident analysis is also an important method of detecting previously undetected or uncorrected hazards. Accident analysis tools include change analysis, PET analysis, MORT and mini-MORT analysis, and event and causal factors charts. 

Other important hazard analysis and control efforts during the operating phases are accident analysis and change analysis. Hazards identified as the result of accidents and changes must be systematically analyzed and controlled to an acceptable level of risk in the same manner as those identified during design. 

Techniques recommended for conducting accident analysis include change analysis, event and causal factors charts, PET analysis (or MORT or mini-... 

Change analysis has applications in both accident prevention and accident investigation. It is recommended for both. 

Change analysis is also a very important accident analysis tool and should be performed as part of any accident investigation. It is particularly well suited... 

The general approach to change analysis, whether for review or accident analysis purposes, is extremely simple (Fig. 17-1). 

The next step is to collect sufficient information about the proposed (or accident) situation and the comparable situation to understand fully the personnel, procedures, plant and hardware, environment, and tasks associated with each. If the change analysis is part of a design review, this step may entail only reviewing relevant drawings and project documentation. However, an accident analysis may require extensive collection and analysis of the people... 

When using change analysis for accident investigation, the accident situation is the evaluated situation. What are the three choices for the comparable situation ... 

After completely evaluating the chart, cross-check results with the event and causal factors chart and change analysis. Reconcile any differences, use all three tools to aid in writing the formal accident report, and be careful to provide findings, conclusions, and recommendations (backed up with evidence) for each factor deemed to be less than adequate. 

Make changes to operating procedures, equipment, and/ortraining based on the accident trend analysis... 

Change Analysis is used when the problem is obscure. It is a systematic process that is generally used for a single occurrence and focuses on elements that were planned and unplanned changes in the system and determines their significance as causal factors in an accident. (See Chapter 10.)... 

Energy Trace and Barrier Analysis -0 Subsystem Hazard Analysis -0 Subsystem Hazard Analysis Accident/Incident Analysis - Change Analysis... 

This is based on the Kepner-Tregoe method of rational decision-making. Change analysis compares a problem-free situation with a problem (accident) situation in order to isolate causes and effects of change. Change analysis is especially useful when the decision-maker needs a quick analysis, when the cause is obscure, and when well-behaved personnel behave differently from past situations, e.g. the Three Mile Island incident. 

Event and cause analysis and barrier analysis are illustrated into a single picture as shown in Figure 2. Based on this chart, the study investigates major accident perspectives in the accident of the Titanic. The change analysis is not included in Figure 2 because it has not so much relevance to this study. 

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. 

Change analysis is a systematic approach that examines planned or unplanned changes in a system that caused the undesirable results related to the accident. 

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