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Incident investigation reliability

System theory can be applied to incident investigation, reliability problems, quality problems, and other business losses. One of several reasons why system theory has received broad recognition relative to incident investigation is that it builds directly on current, verified process safety principles. In process safety, as in all other systems used to control risk to a business, there are three basic keys to controlling the risk (see Figure 3-4) ... [Pg.41]

The source of the data—insurance claims files and records of plant owners — cannot provide reliable accident causal data. From personal experience, 1 can say that insurance claims reports rarely include causal data. And my studies of incident investigation reports completed by supervisors require the conclusion that they are not a reliable source for valid causal data. [Pg.132]

This paper indicates that the use of taxonomies from a bi-dimensional approach such as CREAM to classify data is a potential solution to produce meaningful information from three different types of source using the same framework (i) historical data, as demonstrated in this research, plus (ii) incident investigations and (ii) prospective analysis, as in the original application of CREAM HRA. The common framework to conduct human reliability predictions as well as retrospective analysis of events during Human Reliability Analysis in a specific facility or industry is perfectly able to interface with the proposed classification scheme for past accidents, considering that they basically share the same taxonomy. [Pg.1044]

Ml. Accident and Incident Investigation and Modelling M2. Analytical Methods in System Safety and Reliability M3. Reliability and Safety Management... [Pg.2494]

Given the fact that incident investigation is a process at least as complex as auditing, and given the very limited reliability of auditing (see Chapter 7), we believe that extreme care is necessary in order to ensure a reliable investigation process, hi order to maximize reliability, it is necessary to have a very clearly defined process. This definition should include who should investigate and how. [Pg.100]

It is essential that all incidents are reported promptly, and in detail—even those that have only minor consequences or that are first aid cases or that are near misses. In the United States, incidents that meet the OSHA guidelines for recordability must also be documented and reported. (The topics of Incident Investigation and Root Cause Analysis are discussed in Process Risk and Reliability Management). [Pg.100]

Detailed guidance as to the organization and conduct cf an incident investigation is discussed in Chapter 12 of Process Risk and Reliability Management. [Pg.161]

Like the previous edition, the book remains focused primarily on investigating process-related incidents that present realized or potential catastrophic consequences (that is, accidents as well as near misses). However, readers will find that the methodologies, tools, and techniques described in the following chapters may also be applied when investigating other types of occurrences such as reliability, quality, and occupational health and safety incidents. [Pg.6]

One approach is to mesh all investigation and root cause analysis activities under one management system for investigation. Such a system must address all four business drivers (1) process and personnel safety, (2) environmental responsibility, (3) quality, and (4) profitability. This approach works well since techniques used for data collection, causal factor analysis, and root cause analysis can be the same regardless of the type of incident. Many companies realize that root causes of a quality or reliability incident may become the root cause of a safety or process safety incident in the future and vice versa. [Pg.18]

Detailed fracture and metal failure analysis is usually a very reliable and extensive aspect of investigations of major loss incidents. For most small to medium investigations, macroscopic evaluation is typically sufficient. Macro evidence, such as indications of shear or brittle failure on fracture faces, lines showing detonation direction, and the chevron (herringbone) pattern all provide valuable clues to sequence, type, and cause of the failure.(See Figure 8-9.)... [Pg.164]

The incident and reflected shock-wave technique was employed for a kinetic study of the thermal decomposition of /-butyl bromide110. The substrate dehydrobrominated even at the highest temperature of 1050 K via a unimolecular four-membered cyclic transition state. The A factor and the activation energy obtained in different investigations were compared and, because of the small temperature range in each individual study, these data were combined in order to estimate more reliable Arrhenius parameters between 500 K and 1050 K. Thus ... [Pg.1086]

The incidence of CMIN in the hterature ranges from less than 1% to over 70% [23-27]. This discrepancy results from the lack of a single reliable definition, different methods of investigation, different types of radiological procedures, use of high or low osmolar contrast media and the presence or absence of risk factors. In patients without any risk factor the incidence is less than 1% despite the use of up to 800 ml of contrast media [28]. In patients at high risk the frequency of CMIN has been reported to increase in the last few years, which seems to be related to the wider use of diagnostic and therapeutic interventions in elderly and critically ill patients [29]. Multivariate analysis revealed in-hospital dialysis and an increase in baseline serum creatinine levels as the most important predictors of... [Pg.700]

The committee s analysis was conducted on several levels. First, members investigated the causal factors for each of the seven events listed in Tables 2-1 and 2-2. They then developed a notional causal tree for each of the two events in Table 2-2 that were analyzed in depth. For illustrative purposes, a causal tree developed by the committee for the December 3-5,2000, incident at JACADS appears at Appendix F. The tree is a standard tool in reliability analysis and is particularly useful in human reliability analysis where operator actions contribute either positively or negatively to an incident. Lastly, the committee provides a series of general and specific observations about the events. [Pg.39]


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