chapter 12 incident investigations

swiss cheese model

Updated version of domino model presented by J. Reason Series of dominoes with holes in them Focuses on series of events that must occur for an incident to occur

rac program

a hazard recognition, assessment, and control program; a key element in most health and safety programs

re-anactment

a simulation designed to recreate the circumstances leading up to the incident

Normal Incidents

incidents are expected outcomes of interactive complexities

walkthrough

inspection of the incident scene to get a picture of the total environment

Cognitive Failure

mistake or failure in the performance of an action that an individual is normally capable of performing often a sign of individuals under stress related to occurrence of both motor vehicle and work-related incidents

High-Reliability Organizations

organizations in hazardous industries that maintain a high safety record over time

domino theory

the theory that every incident results from a series of events