BU414 Final Exam Lesson 20
Incident analysis models
Domino theory, Swiss-cheese model, bow-tie analysis and normal incidents
RAC Program
Hazard recognition, assessment and control
Normal Incidents
Incidents are expected outcomes of interactive complexities especially in highly-reliable organizations
Cognitive Failure
Mistake or failure in performance of an action that an individual is normally capable of performing
Swiss-cheese model
Not an isolated event but a series of events where the holes have to line up for an incident to occur
five dominos
Social/environmental/behavioural, faults of person, personal/mechanical hazards due to improper maintence, accidents, injuries
Bow-tie Analysis
combines a fault tree and event tree to look at the hazards and control measures (left bow) and the mitigation measures and results (right bow)
reasons to investigate
determine direct causes, contributing causes, prevent similiar incidents, create a record, determine costs, promote saftey awareness
Domino theory
every incident results from a series of events
Information collected
human, situational and environmental
Four levels of defence
organizational influence, local working conditions, unsafe acts and defences, barriers and safegaurds
Steps to an investigation
secure scene, gather evidence, analyze information, report results, make recommendations, follow up
factors in investigating
timing, severity, legal requirements
Investigation methods
walk through, observations, interviews, re-enactments
