Anomaly, Incident, and Accident Investigation

Causality is, however, much more complex than this simple but very entrenched belief, as has been argued throughout this book. To effect high-leverage policies and changes that are able to prevent large classes of future losses, the weaknesses in the entire safety control structure related to the loss need to be identified and the control structure redesigned to be more effective. 

Chapter 11 describes a way to perform better analyses of anomalies, incidents, and accidents. But having a process is not enough the process must be embedded in an organizational structure that allows the successful exploitation of that process. Two important organizational factors will impact the successful use of CAST training and follow-up. 

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Three general types of feedback are commonly used audits and performance assessments reporting systems and anomaly, incident, and accident investigation. 

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