Contents
Foreword
Preface
PART I
viii
xi
Introduction to the Accident Sequence
Chapter 1What is An Accident?
Definition of Terms
Chapter 2An Accident Happens: What Do You Do?
How Long Do You Do It?
Goals of Accident Investigation
Accident Reporting
Why Do We Need Accident Investigations?
Decisions to Be Made Before an Investigation Begins
Chapter 3 A Short History of Accident Theory Accident Ratio Study
Domino Theories
The Multiple Causation Theory
Cause and Effect Concept
The Epidemiological Model
The Haddon Matrix Theory
Other Accident Causation Theories
Sequence of Events Theory
Chapter 4
Using the Analytical Approach
to Investigate Accidents
The Phases of Accident Investigation
Thinking Analytically
Root Causes and Root Cause Analysis
Layered Investigations
Complex versus Non-Complex Accidents
From Causes to Recommendations
1
3
9
17
33
iii
PART II
Organizing the Investigation
Chapter 5 Investigative Techniques
Are You Ready for an Accident?
Emergency Response Actions
Preservation of Evidence
Types of Evidence
Gathering Evidence
When to Stop Collecting Evidence
43
Chapter 6 The Analytical Process
Causal Analysis
Hazards vs. Failures
Analytical Techniques
59
PART III
67
Analytical Techniques
Chapter 7 Events and Causal Factors Analysis
The Events and Causal Factors Analysis Approach
Events and Causal Factors Charting
Charting Procedures
Charting Tips
Events and Causal Factors Analysis
Example Scenario
69
Chapter 8 Change Analysis
The Change Analysis Approach
Change Analysis Procedures
Example Scenario
83
Chapter 9 Barrier Analysis
The Barrier Analysis Approach
The Barrier Analysis Process
Example Scenario
93
Chapter 10 Tree Analysis The Fault Tree Approach
The Analytic Tree Approach
Example Scenario
iv
41
103
Chapter 11 Cause and Effect Analysis Cause and Effect Approach
Cause and Effect Process
Example Scenario
117
Chapter 12 Specialized and Computerized Techniques
125
PART IV
Specialized Techniques
Time Loss Analysis
Human Factors Analysis
Integrated Accident Event Matrix
Failure Modes and Effects Analysis
Design Criteria Analysis
Other Specialized Techniques
Computerized Techniques
Graphical Programs
Analytical Programs
Preventing Accidents
137
Chapter 13 Recommending Corrective Actions
Causal Factors
Corrective Actions
Example Scenario
139
Chapter 14 Reporting and Follow-up
Reporting
Accident Logs
Accident Forms
Accident Reports
Accident Trending
Follow-up Steps
151
Chapter 15 Learning from Accidents
Lessons Learned
Review Board
Opportunities to Improve the Safety Program
Preventing Systemic Problems
Spreading the Information
159
v
Using Accident Theories and Analytical Techniques to
Prevent Accidents
Analytical Approach to Accidents
Systems Safety Approach
Proactive Safety Techniques Using Accident Theories
APPENDIX 169
Analytical Tree Flowchart
Change Analysis Form
Barrier Analysis Form
Accident Investigation Form
vi
GLOSSARY
175
BIBLIOGRAPHY
179
INDEX
183