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