MHR 711 Lecture Notes - Lecture 12: Organizational Culture, Event Tree, Swiss Cheese Model
Document Summary
Rationale for incident investigation definition + 6 benefits of incident investigation. Domino theory + five dominoes will be on final. Investigation of incidents is an important component of a hazard recognition, assessment, and control (rac) program which in turn is an integral part of a health and safety program: benefits of incident investigation, determines direct causes. Identifies contributing causes: prevents similar incidents, creates a permanent record, determines cost, promotes safety awareness among employees. The steps of an accident investigation: secure the scene, gather evidence, analyze information, report the result of the incident investigation, make recommendations, follow up. Types of information collected: human factors, environmental factors, situational factors, human factors, studying the worker as a source of incidents does not mean that the investigator is looking for a scapegoat. Who investigates: supervisor, the supervisor possesses a detailed knowledge of the work and the working conditions and is therefore well positioned to conduct the investigation, technical advisers and specialists.
