Investigating Accidents With Step

This title was first published in 2002: This volume presents a method to investigate the human performance issues associated with an accident or incident, with a detailed discussion of the types of data to collect, and methods of collecting and analyzing data. The book should be of interest to accident/incident investigators, specialists in nuclear, chemical processing, aviation and other critical industries, safety experts, researchers and students in the field of human error, human factors, ergonomics and industrial engineering, and government agencies for regulation, health and safety.

Providing a practical introduction to the basic theories and principals of accident prevention through diagnosis and feedback control, this book presents the various methods and tools of safety, health, and environment (SHE) practice where experience feedback is employed. These include methods of accident and near accident reporting and investigation, workplace inspection, SHE performance measurement, and safety analysis and auditing. It also assesses potentials and limitations of the different methods and tools, including learning from experience of unwanted events and errors. It includes highly applicable data on developing a computer-supported SHE information system.

This new edition of a standard in the field is the most complete treatment available on modern methods of accident investigation. The investigation process is divided into three phases: preparation and planning, analytical methods and reporting, and corrective actions designed to prevent recurrence. Techniques discussed are general and can be applied to a wide range of industrial accidents. Topics covered include investigation concepts, the pitfalls of government intervention, legal aspects, multilinear events sequencing, and management oversight and risk tree (MORT). There is new material on the electronic and computer industries and on S-T-E-P accident investigation. A new chapter, ``A Generic Approach to Mishap Investigation,'' puts the entire process in perspective.

Every year people are killed or injured at work. Over 40 million working days are lost annually through work-related accidents and illnesses. This workbook can help different organisations, particularly smaller businesses, to carry out their own health and safety investigations.

This book provides a comprehensive treatment of investing chemical processing incidents. It presents on-the-job information, techniques, and examples that support successful investigations. Issues related to identification and classification of incidents (including near misses), notifications and initial response, assignment of an investigation team, preservation and control of an incident scene, collecting and documenting evidence, interviewing witnesses, determining what happened, identifying root causes, developing recommendations, effectively implementing recommendation, communicating investigation findings, and improving the investigation process are addressed in the third edition. While the focus of the book is investigating process safety incidents the methodologies, tools, and techniques described can also be applied when investigating other types of events such as reliability, quality, occupational health, and safety incidents.

In this book the author applies contemporary error theory to the needs of investigators and of anyone attempting to understand why someone made a critical error, how that error led to an incident or accident, and how to prevent such errors in the future. Students and investigators of human error will gain an appreciation of the literature on error, with numerous references to both scientific research and investigative reports in a wide variety of applications, from airplane accidents, to bus accidents, to bonfire disasters. Based on the author's extensive experience as an accident investigator and instructor of both aircraft accident investigation techniques and human factors psychology, it reviews recent human factors literature, summarizes major transportation accidents, and shows how to investigate the types of errors that typically occur in high risk industries. It presents a model of human error causation influenced largely by James Reason and Neville Moray, and relates it to error investigations with step-by-step guidelines for data collection and analysis that investigators can readily apply as needed. This second edition of Investigating Human Error has been brought up to date throughout, with pertinent recent accidents and safety literature integrated. It features new material on fatigue, distraction (eg mobile phone and texting) and medication use. It also now explores the topics of corporate culture, safety culture and safety management systems. Additionally the second edition considers the effects of the reduction in the number of major accidents on investigation quality, the consequences of social changes on transportation safety (such as drinking and driving, cell phone use, etc), the contemporary role of accident investigation, and the effects of the prosecution of those involved in accidents.