Root Causes Analysis (Contract Research Report) by HSE

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2. 4. 6. 7. 9. 11. Can the method be summarised on 2 sides of A4? Can this method be applied by a single analyst? Is the emphasis on organisational arrangements rather then human performance? 8. 10. 12. 1 REFERENCES INCLUDED IN THE TEXT * Indicates papers that have been cited in other references, but have not been read American Institute of Chemical Engineers, Centre for Chemical Process Safety (AIChE), (1992), Guidelines for Investigating Chemical Process Incidents, New York, AIChE Armstrong, ME, (1989), Human Factors in Incident Investigation, in Proceedings of the Human Factors Society 33rd Annual Meeting, 1989, Human Factors Society * Becker, G B.

SORTM identifies human performance difficulties for root cause analysis, finding correctable causes for a specific event. Barrier Analysis: - Like SORTM, barrier analysis can be used to identify human performance difficulties for root cause analysis. It can also be applied to ensure that corrective actions address the root causes, and that violations are identified. HPIP Modules: - This tool essentially identifies important trends or programmatic system weaknesses. Change Analysis: - allows understanding of the event and ensures complete investigation and accuracy of perceptions.

Two columns of empty rectangular boxes are presented on a worksheet, one column relating to human organisational systems and the other to technical component systems. This sheet is used to model the sequence of failures with arrows indicating the interactions. It is assumed that there are barrier functions that can arrest the sequence and prevent the unwanted development of an incident. 5 Work Safety Analysis (WSA) WSA is essentially a method for systematic risk assessment. It is usually applied as a preventative technique rather than an incident investigation tool, although in the AIChE it is argued that the same methods could be applied to incident investigation.

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