Event Investigations

A common fuel for dust explosions, with the distinction of causing the first such event investigated and recorded (in 1795). 

A common fuel for dust explosions, with the distinction of causing the first such event investigated and recorded (in 1795) [1]. The same incident is given in fuller translation, (together with many other unrelated historical explosions) [2]. 

The advances of greatest benefit will be rapid and sensitive assays for microcomponents of organic substances in different media, which will provide verification and justification for initiation of terrorist (subversive) events investigation. 

Ridker, P.M., Rifai, N., Pfeffer, M.A., Sacks, F.M., Moye, L.A.. Goldman, S., Flaker, G.C., Braunwald, E., and Cholesterol Recurrent Event Investigation (1998) Inflammation, Pravastatin, and the Risk of Coronary Events After Myocar-... 

AR149 Precursor analyses - The use of deterministic and PSA-based methods in the event investigation process at nuclear power plants. No. 1417, 1 November 2004. 

The most apparent contributing factor to prolonged duration of rogue trading events is major deficiencies in implemented controls. Post event investigations all turn up results where severaL in hindsight, apparent control weaknesses allowed the event to go undetected. 

Ostrom, L, Leahy, T, Novack, S, Summary of 1991-1992 misadministration event investigations, 1994. 

Failure data (at event, investigation, intervention or repair stage) can be completed by information gathered by SBB or ALSTOM, as the case may be, according to the procedures and responsibilities relevant for RAM performance monitoring. In particular, ALSTOM, SBB and, when applicable, BLS will fill in the same intervention form and send it to the ALSTOM configuration manager. Part replacement information will be collected by ALSTOM at the 3rd level of maintenance. 

The case involved a complex sequence of events. Investigations pointed to many issues, including flawed operating procedures, driver error, a defective locomotive, poor track maintenance, weak regulatory oversight, and lack of safety redundancy. ... 

In addition to the requirements set by local legislation (including an accident register) you will need to ensure that you have set up a detailed event-investigation system designed to educate staff as well as to collect data. There should also be an accident reporting system. 

Accidents and incidents are investi ted so that measures can be taken to prevent a recurrence of similar events. Investigation represents an after-the-fact response as far as any particular mishap is concerned. However, a thorough investigation may uncover hazards or problems which can be eliminated before-the-fact for the future. After causes have been determined, prompt follow-up action is required to achieve the purpose of the investigation. 

Even though an act of nature, a lightning strike, initiated the event, investigations indicated that the subsequent explosion was avoidable and the two companies were fined a total of 200,000 and order to pay 143,700 costs. 

The supervisor, foreman, or manager directly in charge of the area in which the event occurred should be the prime investigator. In some instances, the safety and health representative may have been appointed as the event investigator, but this should not free the immediate manager of his/her responsibilities to investigate the accident or near miss incident. 

Assist in loss-producing event investigations and weekly planned inspections. 

Assist in using the JHAs in loss-producing events, investigations, and reviews. 

Incidents/Near Miss/Loss-Producing Event Investigations... 

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