Integration of Quality Into Accident Investigation Processes ASQ
![Integration of Quality Into Accident Investigation Processes ASQ Columbia Basin Section 614 John Cornelison Integration of Quality Into Accident Investigation Processes ASQ Columbia Basin Section 614 John Cornelison](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-1.jpg)
![Failure of weld on blow down system Failure of weld on blow down system](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-2.jpg)
![Presentation Summary • Outline system processes for investigation, analysis and reporting • Identify quality Presentation Summary • Outline system processes for investigation, analysis and reporting • Identify quality](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-3.jpg)
![Key Elements of Accident Investigation • • Reconstruct what happened Collection of information Analysis Key Elements of Accident Investigation • • Reconstruct what happened Collection of information Analysis](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-4.jpg)
![Performance Logic • The investigation and analysis processes should produce a finished report • Performance Logic • The investigation and analysis processes should produce a finished report •](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-5.jpg)
![Quality Considerations For AI Processes • Written plan and procedures and personnel trained to Quality Considerations For AI Processes • Written plan and procedures and personnel trained to](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-6.jpg)
![Advantages of System Approach • Accidents are complex • Divides accident information into usable Advantages of System Approach • Accidents are complex • Divides accident information into usable](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-7.jpg)
![Accident Model 1) Management Policy drives which barrier and controls used 2) Barriers and Accident Model 1) Management Policy drives which barrier and controls used 2) Barriers and](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-8.jpg)
![AI Model Quality Points • Are your current causal analysis and recommendations preventing similar AI Model Quality Points • Are your current causal analysis and recommendations preventing similar](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-9.jpg)
![Sequence of Events • Accidents involve a sequence of events that set up LTA Sequence of Events • Accidents involve a sequence of events that set up LTA](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-10.jpg)
![Quality Points • Sequence of events in correct order based on time and date Quality Points • Sequence of events in correct order based on time and date](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-11.jpg)
![](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-12.jpg)
![Barriers and Controls • All accidents involve failure of barriers and controls • Investigation Barriers and Controls • All accidents involve failure of barriers and controls • Investigation](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-13.jpg)
![SYSTEMS APPROACH TO ACCIDENT INVESTIGATION BARRIER ANALYSIS Energies/Hazard Physical Barriers Administrative Controls Targets/Value Evaluate SYSTEMS APPROACH TO ACCIDENT INVESTIGATION BARRIER ANALYSIS Energies/Hazard Physical Barriers Administrative Controls Targets/Value Evaluate](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-14.jpg)
![Quality Points • Identifies all the hazards • Separates physical barriers from administrative controls Quality Points • Identifies all the hazards • Separates physical barriers from administrative controls](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-15.jpg)
![Task Performance • Accidents involve work performed which is adequate or LTA • Investigation Task Performance • Accidents involve work performed which is adequate or LTA • Investigation](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-16.jpg)
![SYSTEMS APPROACH TO ACCIDENT INVESTIGATION TASK PERFORMANCE ANALYSIS Event No. Task Description Task Error SYSTEMS APPROACH TO ACCIDENT INVESTIGATION TASK PERFORMANCE ANALYSIS Event No. Task Description Task Error](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-17.jpg)
![Quality Points • Identifies tasks with potential for errors that can degrade system • Quality Points • Identifies tasks with potential for errors that can degrade system •](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-18.jpg)
![Status of Work Processes • Accidents involve many work processes • Each process may Status of Work Processes • Accidents involve many work processes • Each process may](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-19.jpg)
![SYSTEMS APPROACH TO ACCIDENT INVESTIGATION STATUS OF WORK PROCESSES ANALYSIS Event No. Personnel Procedures SYSTEMS APPROACH TO ACCIDENT INVESTIGATION STATUS OF WORK PROCESSES ANALYSIS Event No. Personnel Procedures](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-20.jpg)
![Quality Points • Investigates the OR status of key elements of the work process Quality Points • Investigates the OR status of key elements of the work process](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-21.jpg)
![Change • Most accidents involve some type of change in the work processes • Change • Most accidents involve some type of change in the work processes •](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-22.jpg)
![SYSTEMS APPROACH TO ACCIDENT INVESTIGATION CHANGE ANALYSIS Present Condition Prior Condition Change/Difference Evaluate Affects SYSTEMS APPROACH TO ACCIDENT INVESTIGATION CHANGE ANALYSIS Present Condition Prior Condition Change/Difference Evaluate Affects](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-23.jpg)
![Quality Points • Investigates how changes in the work processes were managed • Looks Quality Points • Investigates how changes in the work processes were managed • Looks](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-24.jpg)
![Causal Factors • Reasons or whys for an accident • Investigation Method – Root Causal Factors • Reasons or whys for an accident • Investigation Method – Root](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-25.jpg)
![Systemic Factors • • • • Management Policy Implementation Risk Assessment Technical Information Hazard Systemic Factors • • • • Management Policy Implementation Risk Assessment Technical Information Hazard](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-26.jpg)
![Specific Factors • • • • Amelioration Barriers & Controls Operational Readiness Maintenance Inspection Specific Factors • • • • Amelioration Barriers & Controls Operational Readiness Maintenance Inspection](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-27.jpg)
![Systems Approach to Accident Investigation Causal Factor Analysis Selection Tree RC Number Causal Factor Systems Approach to Accident Investigation Causal Factor Analysis Selection Tree RC Number Causal Factor](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-28.jpg)
![DC 2 Controls Administrative Information/Communication Operational Ready Maintenance Inspection Supervision DC 3 Task Performance DC 2 Controls Administrative Information/Communication Operational Ready Maintenance Inspection Supervision DC 3 Task Performance](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-29.jpg)
![CC 5 Change Specific Changes CC 6 Programmatic Programs CC 5 Change Specific Changes CC 6 Programmatic Programs](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-30.jpg)
![Quality Points • Looks at a complete system of causes • Systemic and Specific Quality Points • Looks at a complete system of causes • Systemic and Specific](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-31.jpg)
![Summary of The Processes • Use of the Systems Approach Accident Model to drive Summary of The Processes • Use of the Systems Approach Accident Model to drive](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-32.jpg)
![Accident Report • • • Title Page Table of Contents Executive Summary Facts Section Accident Report • • • Title Page Table of Contents Executive Summary Facts Section](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-33.jpg)
![Accident Model 1) Management Policy drives which barrier and controls used 2) Barriers and Accident Model 1) Management Policy drives which barrier and controls used 2) Barriers and](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-34.jpg)
- Slides: 34
![Integration of Quality Into Accident Investigation Processes ASQ Columbia Basin Section 614 John Cornelison Integration of Quality Into Accident Investigation Processes ASQ Columbia Basin Section 614 John Cornelison](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-1.jpg)
Integration of Quality Into Accident Investigation Processes ASQ Columbia Basin Section 614 John Cornelison January 2008
![Failure of weld on blow down system Failure of weld on blow down system](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-2.jpg)
Failure of weld on blow down system
![Presentation Summary Outline system processes for investigation analysis and reporting Identify quality Presentation Summary • Outline system processes for investigation, analysis and reporting • Identify quality](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-3.jpg)
Presentation Summary • Outline system processes for investigation, analysis and reporting • Identify quality points
![Key Elements of Accident Investigation Reconstruct what happened Collection of information Analysis Key Elements of Accident Investigation • • Reconstruct what happened Collection of information Analysis](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-4.jpg)
Key Elements of Accident Investigation • • Reconstruct what happened Collection of information Analysis of facts Determine why it happened Develop findings Decide on recommendations Write report
![Performance Logic The investigation and analysis processes should produce a finished report Performance Logic • The investigation and analysis processes should produce a finished report •](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-5.jpg)
Performance Logic • The investigation and analysis processes should produce a finished report • Investigation and analysis information (facts) should be ready for the final report • Information is filtered through a group of causal factors • The investigator needs to place the information in the right report sections
![Quality Considerations For AI Processes Written plan and procedures and personnel trained to Quality Considerations For AI Processes • Written plan and procedures and personnel trained to](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-6.jpg)
Quality Considerations For AI Processes • Written plan and procedures and personnel trained to them • Experienced investigators • Decisions based on facts and not hearsay • Information and evidence collected controlled • Findings and conclusions based on facts • Recommendations address both Systemic Management findings and Specific work findings • Use of AI Model to drive processes
![Advantages of System Approach Accidents are complex Divides accident information into usable Advantages of System Approach • Accidents are complex • Divides accident information into usable](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-7.jpg)
Advantages of System Approach • Accidents are complex • Divides accident information into usable elements • Focuses on critical barriers and controls • AI Model ensures minimum processes • Structured process for traceability and reliability • Reduces bias
![Accident Model 1 Management Policy drives which barrier and controls used 2 Barriers and Accident Model 1) Management Policy drives which barrier and controls used 2) Barriers and](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-8.jpg)
Accident Model 1) Management Policy drives which barrier and controls used 2) Barriers and controls must be maintained Sequence of Events - Pre Accident - Post Accident Energies Barriers Controls Targets Accident Causal Factors Change - Prior - Present 6) Management must control changes 5) Management must maintain work processes in an operational readiness state 3) Multiple barriers and controls must be used 4) Management must maintain performance acceptable level Task Performance - Adequate - LTA Status of Work Process - Personnel - Procedures - Hardware - Environment OR
![AI Model Quality Points Are your current causal analysis and recommendations preventing similar AI Model Quality Points • Are your current causal analysis and recommendations preventing similar](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-9.jpg)
AI Model Quality Points • Are your current causal analysis and recommendations preventing similar accidents? • Causal factor selection may be LTA • Implementation of recommendations may be LTA • System for investigation and analysis may need to be changed
![Sequence of Events Accidents involve a sequence of events that set up LTA Sequence of Events • Accidents involve a sequence of events that set up LTA](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-10.jpg)
Sequence of Events • Accidents involve a sequence of events that set up LTA conditions – work planning • Investigation method – Event Charting • Recreates sequence of events, what happened • Systemic and specific conditions and causal factors • Is the system functioning as planned
![Quality Points Sequence of events in correct order based on time and date Quality Points • Sequence of events in correct order based on time and date](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-11.jpg)
Quality Points • Sequence of events in correct order based on time and date • Requires a complete investigation to ensure correct order • Looks at both systemic and specific events • Identifies missing sequences • Where did the Systemic and Specific failures occur; in work planning, in implementation or in control processes
![](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-12.jpg)
![Barriers and Controls All accidents involve failure of barriers and controls Investigation Barriers and Controls • All accidents involve failure of barriers and controls • Investigation](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-13.jpg)
Barriers and Controls • All accidents involve failure of barriers and controls • Investigation Method – Barrier Analysis • Identifies energy sources, physical barriers, administrative controls and targets • Evaluates effectiveness of barriers and controls • Determines reliability of barriers & controls
![SYSTEMS APPROACH TO ACCIDENT INVESTIGATION BARRIER ANALYSIS EnergiesHazard Physical Barriers Administrative Controls TargetsValue Evaluate SYSTEMS APPROACH TO ACCIDENT INVESTIGATION BARRIER ANALYSIS Energies/Hazard Physical Barriers Administrative Controls Targets/Value Evaluate](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-14.jpg)
SYSTEMS APPROACH TO ACCIDENT INVESTIGATION BARRIER ANALYSIS Energies/Hazard Physical Barriers Administrative Controls Targets/Value Evaluate B&C
![Quality Points Identifies all the hazards Separates physical barriers from administrative controls Quality Points • Identifies all the hazards • Separates physical barriers from administrative controls](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-15.jpg)
Quality Points • Identifies all the hazards • Separates physical barriers from administrative controls • Examines mode of failure • Identifies all potential targets of value – Personnel, Facilities, Processes, Environment
![Task Performance Accidents involve work performed which is adequate or LTA Investigation Task Performance • Accidents involve work performed which is adequate or LTA • Investigation](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-16.jpg)
Task Performance • Accidents involve work performed which is adequate or LTA • Investigation Method – Task Analysis • Identifies basic tasks • Looks for task errors • Analyzes task errors for “Can Do” and “Motivational Behavioral Climate” • Questions methods to ensure performance
![SYSTEMS APPROACH TO ACCIDENT INVESTIGATION TASK PERFORMANCE ANALYSIS Event No Task Description Task Error SYSTEMS APPROACH TO ACCIDENT INVESTIGATION TASK PERFORMANCE ANALYSIS Event No. Task Description Task Error](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-17.jpg)
SYSTEMS APPROACH TO ACCIDENT INVESTIGATION TASK PERFORMANCE ANALYSIS Event No. Task Description Task Error Evaluate Task Error Risk Level
![Quality Points Identifies tasks with potential for errors that can degrade system Quality Points • Identifies tasks with potential for errors that can degrade system •](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-18.jpg)
Quality Points • Identifies tasks with potential for errors that can degrade system • Identifies task with errors • Looks at how the task errors occurred in the work processes • Quality monitoring to ensure critical systems are not affected by task errors
![Status of Work Processes Accidents involve many work processes Each process may Status of Work Processes • Accidents involve many work processes • Each process may](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-19.jpg)
Status of Work Processes • Accidents involve many work processes • Each process may be in a different state of readiness • Investigation Method – Status of the Work Process Review • Looks closely at personnel, procedures, hardware and environment in OR mode • Time and interfaces
![SYSTEMS APPROACH TO ACCIDENT INVESTIGATION STATUS OF WORK PROCESSES ANALYSIS Event No Personnel Procedures SYSTEMS APPROACH TO ACCIDENT INVESTIGATION STATUS OF WORK PROCESSES ANALYSIS Event No. Personnel Procedures](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-20.jpg)
SYSTEMS APPROACH TO ACCIDENT INVESTIGATION STATUS OF WORK PROCESSES ANALYSIS Event No. Personnel Procedures Hardware Environment OR Status Risk Level
![Quality Points Investigates the OR status of key elements of the work process Quality Points • Investigates the OR status of key elements of the work process](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-21.jpg)
Quality Points • Investigates the OR status of key elements of the work process – Personnel – Procedures – Hardware – Environment • Determines when and how the elements lost their OR status • Set up monitoring points
![Change Most accidents involve some type of change in the work processes Change • Most accidents involve some type of change in the work processes •](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-22.jpg)
Change • Most accidents involve some type of change in the work processes • Investigation Method – Change Analysis • Identifies present conditions and prior conditions • Looks for differences • Analyzes changes for affects on setting up LTA conditions
![SYSTEMS APPROACH TO ACCIDENT INVESTIGATION CHANGE ANALYSIS Present Condition Prior Condition ChangeDifference Evaluate Affects SYSTEMS APPROACH TO ACCIDENT INVESTIGATION CHANGE ANALYSIS Present Condition Prior Condition Change/Difference Evaluate Affects](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-23.jpg)
SYSTEMS APPROACH TO ACCIDENT INVESTIGATION CHANGE ANALYSIS Present Condition Prior Condition Change/Difference Evaluate Affects of Change
![Quality Points Investigates how changes in the work processes were managed Looks Quality Points • Investigates how changes in the work processes were managed • Looks](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-24.jpg)
Quality Points • Investigates how changes in the work processes were managed • Looks at planned and unplanned changes • Looks at the interface of the changes with the key elements of the work processes • Looks at how system performance was affected by the changes
![Causal Factors Reasons or whys for an accident Investigation Method Root Causal Factors • Reasons or whys for an accident • Investigation Method – Root](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-25.jpg)
Causal Factors • Reasons or whys for an accident • Investigation Method – Root Cause Analysis • Identifies Systemic and Specific causes • Looks at chain of causes from management to work and back to management • Groups causes into 27 categories
![Systemic Factors Management Policy Implementation Risk Assessment Technical Information Hazard Systemic Factors • • • • Management Policy Implementation Risk Assessment Technical Information Hazard](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-26.jpg)
Systemic Factors • • • • Management Policy Implementation Risk Assessment Technical Information Hazard Analysis Safety Appraisals / Audits / Reviews Change Procedure Codes / Standards / Regulations Design Human Factors Quality Assurance / Quality Control
![Specific Factors Amelioration Barriers Controls Operational Readiness Maintenance Inspection Specific Factors • • • • Amelioration Barriers & Controls Operational Readiness Maintenance Inspection](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-27.jpg)
Specific Factors • • • • Amelioration Barriers & Controls Operational Readiness Maintenance Inspection Supervision Task Performance Personnel Training Environment Equipment Communications Personnel Protective Equipment
![Systems Approach to Accident Investigation Causal Factor Analysis Selection Tree RC Number Causal Factor Systems Approach to Accident Investigation Causal Factor Analysis Selection Tree RC Number Causal Factor](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-28.jpg)
Systems Approach to Accident Investigation Causal Factor Analysis Selection Tree RC Number Causal Factor Categories Root Causes RC 1 Oversight RC 2 Omission RC 3 Assumed Risk Systemic Causal Factors RC 1 A Policy RC 2 A Policy Implementation RC 3 A Risk Assessment Specific Causal Factors DC 1 Barriers Physical Equipment Safety Systems Select 1 or more from RC 1 -3 Select 1 or more from RC 1 A-3 A Select 1 or more from DC 1 -3
![DC 2 Controls Administrative InformationCommunication Operational Ready Maintenance Inspection Supervision DC 3 Task Performance DC 2 Controls Administrative Information/Communication Operational Ready Maintenance Inspection Supervision DC 3 Task Performance](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-29.jpg)
DC 2 Controls Administrative Information/Communication Operational Ready Maintenance Inspection Supervision DC 3 Task Performance Perform Task Correctly Made Task Error Contributing Causal Factors CC 1 Personnel Criteria Fit For Duty Training Experience Motivated CC 2 Procedures Written Current Followed Match work process CC 3 Hardware Design Human Factors Hazard Analysis QA/QC CC 4 Environment Hot/Cold Vibration Noise Space Stress Select 1 or more from CC 1 -5
![CC 5 Change Specific Changes CC 6 Programmatic Programs CC 5 Change Specific Changes CC 6 Programmatic Programs](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-30.jpg)
CC 5 Change Specific Changes CC 6 Programmatic Programs
![Quality Points Looks at a complete system of causes Systemic and Specific Quality Points • Looks at a complete system of causes • Systemic and Specific](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-31.jpg)
Quality Points • Looks at a complete system of causes • Systemic and Specific • Identifies the complete chain of causal factors • Fixes not just the primary accident causes but all the LTAs in the system
![Summary of The Processes Use of the Systems Approach Accident Model to drive Summary of The Processes • Use of the Systems Approach Accident Model to drive](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-32.jpg)
Summary of The Processes • Use of the Systems Approach Accident Model to drive the investigation • Focuses on fixing all the LTAs in the system • Which prevents future accidents • Use of the systems analysis tools provides valid factual information to accident report • Maintains high level of performance
![Accident Report Title Page Table of Contents Executive Summary Facts Section Accident Report • • • Title Page Table of Contents Executive Summary Facts Section](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-33.jpg)
Accident Report • • • Title Page Table of Contents Executive Summary Facts Section Analysis Section Finding Section Recommendations Signature Appendix
![Accident Model 1 Management Policy drives which barrier and controls used 2 Barriers and Accident Model 1) Management Policy drives which barrier and controls used 2) Barriers and](https://slidetodoc.com/presentation_image_h2/dd325f912f70cbfdb3d499c45f80b720/image-34.jpg)
Accident Model 1) Management Policy drives which barrier and controls used 2) Barriers and controls must be maintained Sequence of Events - Pre Accident - Post Accident Energies Barriers Controls Targets Accident Causal Factors Change - Prior - Present 6) Management must control changes 5) Management must maintain work processes in an operational readiness state 3) Multiple barriers and controls must be used 4) Management must maintain performance acceptable level Task Performance - Adequate - LTA Status of Work Process - Personnel - Procedures - Hardware - Environment OR
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