Causes incidents/accidents

Accident investigation indicates that there are often many individual causes to an accident, and that a series of incidents occur simultaneously to cause the accident. The following figure is called the safety triangle", and shows the approximate ratios of occurrence of accidents with different severities. This is based on industrial statistics. 

In some organizations, designated individuals have specific responsibility for eliciting detailed information from operational staff on the immediate and underlying causes of incidents. An example is the Human Performance Evaluation System (HPES) developed for the nuclear industry, which is described in Bishop and Larhette (1988). These coordinators provide a certain level of guaranteed irrununity from sanctions which allows individuals to be frank about the contributory causes that they may not be willing to discuss in an open forum. As discussed earlier, the need for this approach is a consequence of the fact that in many organizations a blame culture exists which is likely to inhibit a free flow of information about the causes of accidents. 

Coppock, R.W. (2009). Potential agents that can cause contamination of animal feedstuffs and terror. In Handbook of Toxicology of Chemical Warfare Agents (R.C. Gupta, ed.), pp. 739 5. Academic Press/Elsevier, New York. Cunningham, S.A. (2005). Incident, accident, catastrophe cyanide on the Danube. Disasters 29 99-128. 

The two main memory disorders are amnesia and aphasia. Amnesia is a partial or total loss of memory caused by emotional trauma, disease, or brain injury (usually due to head trauma, surgical accidents, or chronic alcohol abuse). Memory loss can occur for events just prior to the amnesia-causing incident (retrograde amnesia), or for events occurring after the incident (anterograde amnesia). In severe cases of anterograde amnesia, the person may be unable to form n memories, although recall of material learned before amnesia s onset is usually unaffected. Many cases of amnesia (even severe) are temporary, so that the person recovers his or her memory. 

INCIDENT CAUSES. Incident causes or initiating events should be readily identifiable in any PrHA method. Reviewers should use their experience to assure that all initiating events, including hardware failure modes, operator errors, administrative errors, and loss of utilities, are considered. If the process is in a location subject to external events, the PrHA should include relevant events such as earthquakes, traffic, weather, or accidents at an adjacent process. 

Within aviation, analyzing the exact causes of accidents and incidents is a nontrivial task. Even if detailed flight data from the black box are available, it is usually still difficult to come up with a clear analysis, for the simple reason that the causes of incidents cannot be attributed to a single point of failure of one individual entity. Instead, most incidents in aviation are found to be caused by a complex interplay of processes at various levels of the socio-technical system, involving pilots, air traffic controllers, technical systems, and their interaction. For example the famous accident in 2009 of Air France Flight 447 is stiU under investigation and seems to have been the consequence of a rare combination of factors. On May 31, 2009, this flight disappeared... 

There even seem to be differences in causal attribution between accidents and incidents Accident investigation data on near-miss (incident) reporting suggest that causes for these events are mainly attributed to technical deviations while similar events that result in losses are more often blamed on operator error [62,100]. 

In Chapter 7, Heinrich Revisited Tmisins or Myths, comments are made on Heinrich s often expressed premise that the predominant causes of no-injury accidents are identical to the predominant causes of accidents resulting in major injuries. I said that I found the premise to be invalid. Furthermore, I made the case that a large proportion of the incidents resulting in serious injuries are singular and unique events, that their causal factors are multifaceted and complex, and that descriptions of similar accidents are seldom found in the historical body of incident data. 

A future chapter will be devoted to effective incident/accident investigations. Every incident (near miss) or accident provides a continuous improvement opportunity that should result in root cause analysis and corrective actions. Here is a chance to utilize someone with a passion for lean, and his/her problem-solving skill sets, to fill this safety team position. Eilling this role provides another opportunity to develop a future business leader. 

The principle of multiple causes states Accidents, near-miss incidents, and other problems are seldom, if ever, the result of a single cause. 

As stated by the principle of definition, if the real causes of accidents and near-miss incidents are not found, how can real solutions be proposed If all the contributing factors are not investigated, how can the causes of the events be identified and rectified ... 

Participating on workplace teams charged with identifying root causes of accidents, incidents, or breakdowns. 

Local impact - denoting impact coming from dedicated components causing concentrated accidents or incidents. 

Circumstances conducive to incidents/accidents effected by the violation of rules and regulations may be classified as causes of (Reason 1990)... 

Errors in flying skills and in operating the aircraft are causes of a wide range of air events. They can considerably affect flight safety. In this category, the following are the most common factors that can result in an air incident/accident ... 

Investigation into each and any of air events should be started with reconstruction of particular links of the chain of errors , which at the same time is the chain of causes . The chain of errors is a term that describes errors in human-performed actions as effects of a series of coincidences that result in an incident/accident. Since any chain shows no more strength than its weakest link, removal of that weakest link could potentially prevent the accident, or reduce the probability that the accident occurs, or possibly reduce the effects. 

Air incident/accident investigation is very complicated. Reconstruction of the course of the event and determination of causes of its occurrence demand many-months intensive work of experts in many and various fields of science. The air accident investigation is often based on fragmentary, not always fully reliable data. Finding the reasons for a given event to occur proves thus even more difficult. According to Polish civil law (legal system) currently n force, based on the final report issued by the State Commission on... 

This analysis should be done from the beginning of the operation and must ensure the full and exhaustive list of incidents / accidents and may have consequences on the safety of personnel or material. Its goal is to move to list the dangers of the system and its possible causes, evaluating the quality of the gravity of the consequences of accidents and the implementation of corrective actions. 

The primary causes of accidents in the chemical industry are technical failures, human failures and the chemical reaction itself (due to lack of knowledge of the thermochemistry and the reaction kinetics) [156]. As discussed previously, polymerization reactions are subject to thermal runaway, so that it is not surprising to learn that polymerization reactions (64 from 134 cases) are more prone than other processes to serious accidents [157]. Among the polymerization processes, the phenol-formaldehyde resin production seems to be the worst case, although incidents have been reported for vinyl chloride, vinyl acetate and polyester resins polymerization processes. 

Normally refers to insurance coverage for bodily injury and death resulting from accidental means (other than natural causes). For example, an insured person is critically injured in an incident. Accident insurance can provide income and/or a death benefit if death ensues. 

A detailed, defined, and recorded review of an incident undertaken to identify and record the causes and contributing factors and their relationships, which led up to and caused the incident. Accident Investigation is a technique that allows an organization to learn from its experience. The intent of an incident investigation is for employers to learn from past experiences and thus avoid repeating past mistakes. See also Incident Investigation Team. 

A theory of accident (incident) causation proposed in the early twentieth century, by various researchers, which has been discredited. Originally it used to attribute the cause of accidents to personality traits of individuals or groups of workers. In 1971,... 

Hallock, R. G., Technic of Operations Review Analysis Determine Cause of Accident/Incident, Safety and Health, Vol. 60, No. 8,1991, pp. 38-39,46. 

Reports of incidents that in slightly different circumstances could have caused an accident. 

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