Anatomy of an Accident

When considering how an accident can occur, or its anatomy, it is important to realize that it is very rare, if ever, that a single event will lead to an accident. Chapter 2 discusses preliminary, initiating, and intermediate events that can lead up 

New law% regulations, and standards Organizational complexity Rapid increase in implementing new, advanced technologies H uman error and difficulty for humans to a comprehend new systems  

Global impact of local accidents Interconnectivity and dependencies between systems Cyber-based control systems Dynamic interdependencies Increased international alliances 

Market instability and fluidity Corporate finandal instability Higher insurance costs Increased movement of labor Global warmii and natural disasters Increased public perception risk to brand 

FIGURE 11.1 (See color insert.) Changing operating environment and its challenges. 

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A generic fault tree that describes how an accident - details unspecified - can happen is known as the anatomy of an accident, see Figure 2.2. According to this description an accident begins when an unexpected event occurs while the system is working normally. The unexpected event can itself be due to an external event or a latent condition that for some reason suddenly becomes manifest. Unless the unexpected event can be immediately neutralised, it will move the system from a normal to an abnormal state. In the abnormal state attempts will be made... 

The anatomy of an accident can be found in Green, A.E. (1988), Human factors in industrial risk assessment - some early work, in Goodstein, L.P., Andersen, H.B. and Olsen, S.E. (eds). Task, Errors and Mental Models, London Taylor Francis. The anatomy is a generic Fault Tree that can be expanded recursively. Failure of control, for instance, can be seen as the top event of another anatomy Fault Tree, and so on. In that sense the anatomy is a general fault model. 

One of the very best all-around CSB videos is titled An Anatomy of Disaster Explosion at BP Texas City Refinery, March 28,2005 [13]. It tells the story of one of the worst industrial accidents in recent US history in words, animation and site footage. This refinery explosion arrd fire killed 15 workers, injured 180 others and resrrlted in billions of dollars in econorrtic losses. This video is nearly 56 rrrin long, but is divided into chapters. So, you can select chapters to show to certain audiences. 

Fractures of both the femur and the tibia results in an unstable middle segment, the floating knee . These injuries are fortunately rare and typically result from road traffic accidents. One or both fractures may be open and there is often associated head or thoracic trauma. Healing is slow due to the significant soft tissue trauma and it is difficult to maintain alignment of the limb. In view of this, it is recommended that at least one of the fractures should be surgically stabilised. The advent of ESIN which can be inserted with minimal soft tissue trauma has seen a trend towards internal fixation of both fractures, providing the local anatomy allows. This approach is precluded if one or other fracture is in close proximity to the joint. The fractures have been classified by Letts and Vincent (Letts et al. 1986). 

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