Incident investigation work methods

It is illogical to conclude in an incident investigation that the principal causal factor is the unsafe act of the worker if the design of the workplace or the work methods is error-provocative. In such cases, the error-provocative aspects of the work should be considered primary. (A few organizations are giving courses on Preventing Human Error which focus on how to identify and prevent what they are calling error-likely work situations. This is a recent development.)... 

Of the 15 variations of incident investigation reports received, six promote an overly simplistic and inappropriate approach to causal factor determination. They reflect this instmction, although somewhat ancient, given in a publication of the American National Standards Institute, the Method of Recording Basic Facts Relating to the Nature and Occurrence of Work Injuries—Z16.2. 

For instance, incident investigation methods should direct inquiry very early on into what may have been programmed into work systems through the design of the workplace or work methods. They should promote inquiry that determines whether the design of the work is error-conducive. For all injuries, the first question should be. Are there workplace design or work methods design implications ... 

Be considered as a prime source for selecting leading indicators for safety management system improvement. Because—If incident investigation is done well, the reality of the technical, organizational, methods of operation, and cultural causal factors in the work system will be revealed. 

It is illogical to conclude in an incident investigation that the principal causal factor is the worker s unsafe act if the design of the workplace or the work methods is error inviting. In such cases, the... 

Fatality reports, only, were received from the federal government entity. Their thoroughness was commendable. Seldom do comments in incident investigation reports relate to the inadequacy of policies set at an upper management level, or of the appropriateness of standards and procedures, or decisions made affecting the design of the workplace and work methods. These reports did so.Tliey prove that it can be done. 

For how many incidents have the decisions affecting the sociotechni-cal workplace and work methods resulted in situations that are conducive to operator errors In Chapter 14, Incident Investigation Studies of Quality, it was said that in a substantial number of the investigation reports collected by this author, entries suggested that further inquiry should have been made into the design of the workplace or work methods. In many cases, the investigation reports pertained to incidents that occurred in error-provocative situations. Yet, often in those instances, only unsafe acts of employees would be recorded as the incident causal factors. 

A variety of surface-sensitive spectroscopic and microscopic methods were critical in the investigation of these systems. In the work by Advincula et al, the composition, thickness, physical and thermal properties, and morphology of the tethered polymer brushes were carefully analyzed [72]. A variety of surface-sensitive techniques such as ellipsometry, contact angle measurements, AFM, quartz crystal microbalance (QCM), FT-IR grazing incidence... 

Laboratory-based methods have been developed for field-measurement of the main water quality parameters, and their use can be standardized. They are generally based on the same principles as the equivalent laboratory based methods (e.g. oxidation, colorimetry, photometry) but use simplified procedures in order to overcome the constraints of working in the field. Currently there are numerous commercially available devices for online and on-site use, and these provide efficient tools for surveillance, operational and investigative monitoring in the frame of WFD. These techniques are suitable for such applications as incident detection in water treatment plants, detection of accidental pollution, and measurement of spatial and temporal variation in water... 

The present work is concerned with the influence of the pretreatment of an alumina-aerogel supported Pd catalyst on its activity in propane oxidation. The state of Pd and the crystalline state of alumina aerogel were investigated by grazing-incidence X-ray diffraction (GIXD). To our knowledge, this method is applied for the first time to supported metal catalysts. In addition, a comparison of the structural and catalytic oxidation properties of Pd, Pt and Pt-Rh supported on alumina carriers was made. 

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