Investigating Accidents with STEP

Kingsley Hendrick and Ludwig Benner, Jr. make similar comments about the cascading effect of events in accident occurrences in Investigating Accidents with Step. 

Hendrick, Kingsley and Ludwig Benner, Jr. Investigating Accidents with STEP. New York Marcel Dekker, 1987. 

In Investigating Accidents With STEP An accident is a special class of process by which a perturbation transforms a dynamically stable activity into unintended interacting changes of states with a harmful outcome (p. 27). 

Benner in Investigation Accidents with Step says ... 

Hendrick, K. and Benner L Jr. 1987. Investigating Accidents with STEP, Marcel Dekker, New York. 

Passmore, D.L. 1988. Investigating Accidents with Step—Hendrick, K, Benner, L. Accident Analysis and Prevention, 20, 153-154. 

Automotive accidents are investigated by analyzing glass and paints. One way to match the glass from a broken windshield found at a hit-and-run accident scene is to compare elemental profiles. Inductively coupled plasma (ICP) mass spectrometry is an ideal method for this purpose [67]. Acid digestion is used for sample preparation. The use of laser ablation, coupled with ICP-MS, obviates the need for the laborious and time-consuming acid-digestion step [68]. 

As with vehicle accidents, you need to conduct an investigation of your on-the-job injuries and illnesses. Such an investigation may be required by your insurance company. Your investigation should incorporate a number of steps ... 

Causal factor analysis is used when there are multiple problems with a long causal factor chain of events. A causal factor chain is a sequence of events that shows, step by step, the events that took place in order for the accident to occur. Causal factor analysis puts all the necessary and sufficient events and causal factors for an accident in a logical, chronological sequence. It analyzes the accident and evaluates evidence during an investigation. It is also used to help prevent similar accidents in the future and to validate the accuracy of pre-accidental system analysis. It is used to help... 

With regard to future experiments,Woodhouse suggested that the Minister should not adopt a system of indemnities that placed responsibility upon those volunteering for the experiments, but instead pay appropriate compensation where such fatal accidents occurred. He urged the Ministry not to resume tests until Maddison s alleged personal idiosyncrasy had been fully investigated, since other men might have similar conditions, and it was advised to take all reasonable steps to prevent further deaths. If this was not... 

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