Information, systemic causation

One test of the efficiency of a data collection system is whether near-miss incidents are reported and recorded. Their investigation will provide the same information on causation as real injury incidents. 

Analysis, that can assist with the identihcation of causal factors. The concepts of incident causation encompassed in these tools are fundamental to the majority of investigation methodologies. (See Chapter 3 for information about the Domino Theory, System Theory, and HBT Theory.) The simplest approach involves reviewing each unplanned, unintended, or adverse item (negative event or undesirable condition) on the timeline and asking, Would the incident have been prevented or mitigated if the item had not existed If the answer is yes, then the item is a causal factor. Generally, process safety incidents involve multiple causal factors. 

There are four main uses of injury statistics (1) to identify high-risk jobs or work areas, (2) to evaluate company health and safety performance, (3) to evaluate the effectiveness of hazard-abatement approaches, and (4) to identify factors related to illness and injiuy causation. An illness and injuryreporting and analysis system requires that detailed information must be collected about the characteristics of illness and injuries and their frequency and severity. The Occupational Safety and Health Act (1970) established iUness and injury reporting and recording requirements that are mandatory for aU employers, with certain exclusions such as small establishments and government agencies. Regulations have been developed to define how employers are to adhere to these requirements (BLS 1978). 

Experience has shown that there have been occasions when hazards and potential accident causation factors have gone undetected because the workplace was not inspected under normal working conditions. There should not be an underestimation of the possible benefits that can be realized from having workplace inspections conducted by people who do not regularly work in the area. People carrying out inspections who are unfamiliar with a particular workplace or work system are forced to ask questions of the locals. The resulting exchange of information can lead to the identification of opportunities to improve safety levels overlooked by the locals because of either familiarity or complacency with their own work environment. 

Not withstanding, the insurance data were almost devoid of causation information beyond the active failures which occurred immediately before the events. There was little or no data on the organizational circumstances or other latent systems failures which may have been precursors to the events. 

Cardiovascular A retrospective data mining analysis of the United States Food and Drug Administration (FDA) adverse event report system database identified 10 cases (2 male, mean age 37.4 years) of thrombotic events associated with administration of one Cl esterase inhibitor product (Cinryze ). The authors identified an elevated IC025 (the lower limit of the 95% two-sided Cl of the information component) of 2.91 suggesting a higher than expected likelihood of causation between product administration and thrombotic-related preferred terms used in the analysis [36 ]. 

Moreover, harmonized data and information regarding accident causation, across a number of European countries, was used, exploiting the in-depth Safety Net Accident Causation Database collected from six countries following a common methodology and, importantly, a detailed process for recording causation is called the SafetyNet Accident Causation System (SNACS). This resoirrce includes 1,006 cases split between Germarty, Italy, The Netherlands, Finland, Sweden and the UK and was used to produce some basic causation factors. 

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