Reference for Causal Factors and Corrective Actions

DESIGNER INCIDENT INVESTIGATION REPORTS, AND A REFERENCE FOR CAUSAL FACTORS AND CORRECTIVE ACTIONS... 

Since personnel who make very few incident investigations in a year would benefit from having a thought prompter, a draft of a Reference for Causal Factors and Corrective Actions is provided. 

At this point, the designer of the form has at least two options. One is to give instructions such as those in items 25 and 26 and provide a separate, detailed Reference for Causal Factors and Corrective Actions. Or, the form designer could select from the Reference for Causal Factors and Corrective Actions those subjects appropriate to operations and enter them directly on the form, preceded by check-off boxes, as a part of items 25 and 26. A form can be designed, albeit using small print, that includes abbreviations of 20 or more of the causal factors and all of the corrective actions included in the exhibit that follows, leaves enough room... 

If a Reference for Causal Factors and Corrective Actions as thorough as the following is to provided, it could be included as pages 3 and 4 of the Incident Investigation Report Form. (In readable print, it can easily be contained in two pages.) Or, it could be a stand-alone reference (peihaps encased in plastic for preservation purposes) to be maintained in a suitable file, or just included in the procedure manual containing the instractions on incident investigation. 

I emphasize that this Reference For Causal Factors and Corrective Actions is presented as a resource for the designer of an incident investigation system, with the assumption that the designer would make revisions in it to suit organizational needs. 

In Chapter 3, Serious Injury Prevention, an outline for such a study was presented under the heading Proposing a Study of Serious Injuries. Such a study will not be time-consuming since the data to be collected and analyzed should already exist or can be obtained easily. To assist in such a study, two addenda are provided at the conclusion of this chapter. Both are reprinted Ifom the third edition of On The Practice Of Safety Addendum A, A Systemic Causation Model for Hazards-Related Incidents, and Addendum B, Reference for Causal Factors and Corrective Actions. Another good reference when completing this evaluation, in terms of its comments on human errors that may be made above the worker level, is Chapter 4 here. 

A REFERENCE FOR THE SELECTION OF CAUSAL FACTORS AND CORRECTIVE ACTIONS FOR INCIDENT INVESTIGATION PROCEDURES AND REPORTS... 

This chapter briefly sets forth the fundamentals for incident investigation, makes reference to the previously mentioned Guide for Identifying Causal Factors Corrective Actions, and discusses incident costs. 

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