This new edition covers all aspects of accident investigation from theory to organizing, gathering and analyzing data, to reporting, recommendations and follow-up. Special features include in-depth descriptions of analytical techniques in order to understand the strengths and weaknesses of each technique. New chapters include “What is an Accident,” “Cause and Effect Analysis,” and “Learning from Accidents.” The book is divided into four parts: Part I is an introduction to the accident sequence. Part II describes the organization of accident investigations: starting the investigation, gaining knowledge about the accident, collecting evidence and data, and using appropriate investigative techniques. It includes instructions for gathering information, interviewing, documenting, preserving evidence, retrieving data, and analytically processing this information to determine exactly what happened. Part III provides thorough explanations of analytical techniques that are useful in investigating accidents. Numerous examples and worksheets are included, and the benefits, weaknesses, and appropriateness of each technique are discussed. Four chapters of Part III are devoted to specific techniques, and a fifth chapter covers other specialized and computerized techniques. After you use analytical techniques to determine what happened, the next step is to use that information to prevent future accidents. Part IV covers accident documentation and follow-up activities, and tells how to develop recommendations and corrective actions.
Author: Jeffrey S. Oakley
ISBN Print: 978-1-885581-62-4
ISBN Digital: 978-1-885581-91-4
Format: Print and Digital
Publisher: American Society of Safety Engineers
Copyright: 2012
Pages: 188
About the Author
Jeffrey S. Oakley, Ph.D., CSP, is the Department Chair in Occupational Safety and Health at College of the Mainland and Director of the Gulf Coast Safety Institute. Dr. Oakley has spent most of his career either conducting, researching, or training on accident investigations and performing safety and risk assessments. He has conducted accident investigations for the Department of Energy, corporations, and private companies which involved catastrophic property loss and accidents resulting in fatalities. He has also developed and conducted numerous accident investigation and causal analysis training courses for the Department of Energy, general industry, construction, and insurance companies. he is owner/consultant with The Safety Edge, LLC.
Table of Contents
Foreword
Preface
Acknowledgments
PART I Introduction to the Accident Sequence
Chapter 1 What is An Accident?
1.1Definition of Terms
1.2 Accidents versus Incidents
Chapter 2 An Accident Happens: What Do You Do? How Long Do You Do It?
2.1 Goals of Accident Investigation
2.2 Accident Reporting
2.3 Why Do We Need Accident Investigations?
2.4 Decisions to Be Made Before an Investigation Begins
Chapter 3 A Short History of Accident Theory
3.1 Accident Ratio Study
3.2 Domino Theories
3.3 The Multiple Causation Theory
3.4 Cause and Effect Concept
3.5 The Epidemiological Model
3.6 The Haddon Matrix Theory
3.7 Other Accident Causation Theories
3.8 Sequence of Events Theory
Chapter 4 Using the Analytical Approach to Investigate Accidents
4.1 The Phases of Accident Investigation
4.2 Thinking Analytically
4.3 Root Causes and Root Cause Analysis
4.4 Layered Investigations
4.5 Complex versus Non-Complex Accidents
4.6 From Causes to Recommendations
PART II Organizing the Investigation
Chapter 5 Investigative Techniques
5.1 Are You Ready for an Accident?
5.2 Emergency Response Actions
5.3 Preservation of Evidence
5.4 Types of Evidence
5.5 Gathering Evidence
5.6 When to Stop Collecting Evidence
Chapter 6 The Analytical Process
6.1 Causal Analysis
6.2 Hazards vs. Failures
6.3 Analytical Techniques
PART III Analytical Techniques
Chapter 7 Events and Causal Factors Analysis
7.1 The Events and Causal Factors Analysis Approach
7.2 Events and Causal Factors Charting
7.3 Charting Procedures
7.4 Charting Tips
7.5 Events and Causal Factors Analysis
7.6 Example Scenario
Chapter 8 Change Analysis
8.1 The Change Analysis Approach
8.2 Change Analysis Procedures
8.3 Example Scenario
Chapter 9 Barrier Analysis
9.1 The Barrier Analysis Approach
9.2 The Barrier Analysis Process
9.3 Example Scenario
Chapter 10 Tree Analysis
10.1 The Fault Tree Approach
10.2 The Analytic Tree Approach
10.3 Example Scenario
Chapter 11 Cause and Effect Analysis
11.1 Cause and Effect Approach
11.2 Cause and Effect Process
11.3 Example Scenario
Chapter 12 Specialized and Computerized Techniques
12.1 Specialized Techniques
12.2 Time Loss Analysis
12.3 Human Factors Analysis
12.4 Integrated Accident Event Matrix
12.5 Failure Modes and Effects Analysis
12.6 Design Criteria Analysis
12.7 Other Specialized Techniques
12.8 Computerized Techniques
12.9 Graphical Programs
12.10 Analytical Programs
PART IV Preventing Accidents
Chapter 13 Recommending Corrective Actions
13.1 Causal Factors
13.2 Corrective Actions
13.3 Example Scenario
Chapter 14 Reporting and Follow-up
14.1 Reporting
14.2 Accident Logs
14.3 Accident Forms
14.4 Accident Reports
14.5 Accident Trending
14.6 Follow-up Steps
Chapter 15 Learning from Accidents
15.1 Lessons Learned
15.2 Review Board
15.3 Opportunities to Improve the Safety Program
15.4 Preventing Systemic Problems
15.5 Spreading the Information
15.6 Using Accident Theories and Analytical Techniques to Prevent Accidents
15.7 Analytical Approach to Accidents
15.8 Systems Safety Approach
15.9 Proactive Safety Techniques Using
15.10Accident Theories
APPENDIX
Analytical Tree Flowchart
Change Analysis Form
Barrier Analysis Form
Accident Investigation Form
GLOSSARY
BIBLIOGRAPHY
INDEX
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