Anatomy of an incident

Abstract

A traditional view of incidents is that they are caused by shortcomings in human competence, attention, or attitude. It may be under the label of ''loss of situational awareness, '' procedure ''violation,'' or ''poor'' management. A different view is that human error is not the cause of failure, but a symptom of failuretrouble deeper inside the system. In this perspective, human error is not the conclusion, but rather the starting point of investigations. During an investigation, three types of information are gathered: physical, documentary, and human (recall/experience). Through the causal analysis process, apparent cause or apparent causes are identified as the most probable cause or causes of an incident or condition that management has the control to fix and for which effective recommendations for corrective actions can be generated. A causal analysis identifies relevant human performance factors. In the following presentation, the anatomy of a radiological incident is discussed, and one case study is presented. The contributing factors that caused a radiological incident are analyzed. Underlying conditions, decisions, actions, and inactions that contribute to the incident are identified. This includes weaknesses that may warrant improvements that tolerate error. Measures that reduce consequences or likelihood of recurrence are discussed.

Investigation of a light fixture fire

“…See Figure 1. As previously reported in this Journal, 4 a causal analysis of drum handling incidents uncovered contributing factors that created the environment in which the incident reported herein existed. Latent organizational conditions that create error-likely situations or weaken defenses were identified and controlled.…”

“…The use of cause and effect diagrams in the analysis of glove breaches and failures and air-purifying respirator and drum handling incidents, have been previously reported in this journal. 4 Installation of the wrong bulb was the active error that triggered the immediate, undesired consequences: a small fire, as shown in Figure 1. In this case study, engineering, equipment, human performance, and management issues were uncovered.…”

“…The previous paper in this series published in this journal discussed the value of a Lessons Learned Program. 4 As the causal node, A4B1C06, in…”

“…First, the incident was described. 4 A -Fact Finding‖ meeting was conducted to establish a timeline. Causal factors were determined.…”

Investigation of a “Sharps” incident

“…The methodology described in a previous case study of a drum handling incident was again followed. 3 First, the incident was described. A "Fact Finding" meeting was conducted to establish a timeline.…”