Contents

Preface

 

xi

PART I

Introduction to the Accident Sequence.

1
Chapter 1
An Accident Happens: What Do You Do? How Long Do You Do It?
3
  Definition of Terms  
  Goals of Accident Investigation  
  Accident Reporting  
  Why Do We Need Accident Investigations?  
  Decisions to Be Made Before an Investigation Begins  
Chapter 2
A Short History of Accident Theory
15
  Accident Ratio Study  
  Domino Theories  
  The Multiple Causation Theory  
  The Epidemiological Model  
  The Haddon Matrix Theory  
  Other Accident Causation Theories  
  Sequence of Events Theory  
Chapter 3
Using the Analytical Approach to Investigate Accidents
29
  The Phases of Accident Investigation  
  Thinking Analytically  
  Root Causes and Root Cause Analysis  
  Layered Investigations  
  From Causes to Recommendations  

PART II

Organizing the Investigation

37
Chapter 4
Investigative Techniques
39
  Are You Ready for an Accident?  
  Emergency Response Actions  
  Preservation of Evidence  
  Types of Evidence  
  Gathering Evidence  
  When to Stop Collecting Evidence  
Chapter 5
The Analytical Process
55
  Causal Analysis  
  Causal Analysis Example  
  Hazards vs. Failures  
  Analytical Techniques  
  Benefits of Using Analytical Techniques  

PART III

Analytical Techniques

63
Chapter 6
Events and Causal Factors Analysis
65
  The Events and Causal Factors Analysis Approach  
  Events and Causal Factors Charting  
  Charting Procedures  
  Charting Tips  
  Events and Causal Factors Analysis  
  Example Scenario  
Chapter 7
Change Analysis
79
  The Change Analysis Approach  
  Change Analysis Procedures  
  Example Scenario  
Chapter 8
Barrier Analysis
89
  The Barrier Analysis Approach  
  The Barrier Analysis Process  
  Example Scenario  
Chapter 9
Tree Analysis
99
  The Fault Tree Approach  
  The Analytic Tree Approach  
  Example Scenario  
Chapter 10
Specialized and Computerized Techniques
113
  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  

PART IV

Preventing Accidents

125
Chapter 11
Recommending Corrective Actions
127
  Causal Factors  
  Corrective Actions  
  Example Scenario  
Chapter 12
Reporting and Follow-up
139
  Reporting  
  Accident Logs  
  Accident Forms  
  Accident Reports  
  Accident Trending  
  Follow-up Steps  

APPENDIX

  

147
  Analytical Tree Flowchart  
  Change Analysis Form  
  Barrier Analysis Form  
  Accident Investigation Form  

GLOSSARY

  

153

BIBLIOGRAPHY

  

157

INDEX

  

161