Pre-Accident Investigations PDF
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Pre-Accident Investigations To everyone who has ever asked “how” instead of “why.” Pre-Accident Investigations An Introduction to Organizational Safety TODD CONKLIN Los Alamos National Laboratory, USA ASHGATE © Todd Conklin 2012 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without the prior permission of the publisher. Published by Ashgate Publishing Limited Wey Court East Union Road Farnham Surrey GU9 7PT England Ashgate Publishing Company Suite 420 101 Cherry Street Burlington VT 05401-4405 USA www.gowerpublishing.com Todd Conklin has asserted his moral right under the Copyright, Designs and Patents Act, 1988, to be identified as the author of this work. British Library Cataloguing in Publication Data Conklin, Todd. Pre-accident investigations : an introduction to organizational safety. 1. Industrial safety. I. Title 658.3′8-dc23 ISBN: 978-1-4094-4783-2 (hbk) ISBN: 978-1-4094-4782-5 (pbk) ISBN: 978-1-4094-4784-9 (ebk-PDF) ISBN: 978-1-40948354-0 (ebk-ePUB) Library of Congress Cataloging-in- Publication Data Conklin, Todd. Conklin, Todd. Pre-accident investigations : an introduction to organizational safety / by Todd Conklin. p. cm. Includes bibliographical references and index. ISBN 978-1-4094-4783-2 (hardback) -- ISBN 978-1-4094-4782-5 (pbk) -- ISBN 978-1-4094-4784-9 (ebook) 1. Industrial safety. I. Title. T55.C645 2012 363.1′065--dc23 2012004878 Printed and bound in Great Britain by the MPG Books Group, UK Contents List of Figures List of Abbreviations Foreword: A Context Setting Discussion Preface Acknowledgments 1 A Story of a Failure 2 Why Think about Failure at All, Let Alone Think “Differently” about Failure? Case Study: The Titanic: A Story to Help You Rethink How You Think About Failure 3 Change the Way Your Organization Reacts to Failure Pre-Accident Investigation Tool Case Study: Aviation Accidents are the Unexpected Combination of Normal Aviation Variability 4 Workers Don’t Cause Failure, Workers Trigger Failure 5 Change is Better When You Manage Change—And Change Needs to be Managed Case Study: Nine Senior Managers, a Million Different Opinions on How to Handle a Problem…and Nobody Willing to Change 6 Thinking about Where Failure Will Happen Case Study: A Crashing Limb: Thinking about where Failure will Happen 7 Fundamentals Training: Introducing the “New View” to Your Old Crew Case Study: How to Win Friends and Influence Workers 8 Starting the Journey—The First Steps 9 The Four Things that Matter Conclusion Basic Reading List for Human Performance Index List of Figures 1.1 The Three Parts of Every Failure 4.1 Adaptive Nature of Work as Performed 4.2 Operational Learning Happens Every Time a Task is Performed 4.3 Actual Safety Margin 6.1 Critical Steps Imagined and Prioritized List of Abbreviations ATIS Automated Traffic Information System “Sierra” CQD Antiquated nautical “attention all stations” distress or danger call DFEO Deviation From Expected Outcome HAZCOM Hazard Communication HR Human Resources JHA Job Hazard Analysis JSA Job Safety Analysis LANL Los Alamos National Labortatory LOTO Lock Out Tag Out MPH Miles Per Hour MYG Titanic call letters OSHA Occupational Safety and Health Administration RCA Root Cause Analysis SOS Nautical distress call TOGA Flight deck intercom
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