Preface |
Acknowledgments |
Introduction / 1: |
Building on the Past / 1.1: |
Who Should Read This Book? / 1.2: |
The Guideline's Objectives / 1.3: |
The Continuing Evolution of Incident Investigation / 1.4: |
Designing an Incident Investigation Management System / 2: |
Preplanning Considerations / 2.1: |
An Organization's Responsibilities / 2.1.1: |
The Benefit of Management's Commitment / 2.1.2: |
The Role of the Developers / 2.1.3: |
Integration with Other Functions and Teams / 2.1.4: |
Regulatory and Legal Issues / 2.1.5: |
Typical Management System Topics / 2.2: |
Classifying Incidents / 2.2.1: |
Other Options for Establishing Classification Criteria / 2.2.2: |
Specifying Documentation / 2.2.3: |
Describing Team Organization and Functions / 2.2.4: |
Setting Training Requirements / 2.2.5: |
Emphasizing Root Causes / 2.2.6: |
Developing Recommendations / 2.2.7: |
Fostering a Blame-Free Policy / 2.2.8: |
Implementing the Recommendations and Follow-Up Activities / 2.2.9: |
Resuming Normal Operation and Establishing Restart Criteria / 2.2.10: |
Providing a Template for Formal Reports / 2.2.11: |
Review and Approval / 2.2.12: |
Planning for Continuous Improvement / 2.2.13: |
Implementing the Management System / 2.3: |
Initial Implementation-Training / 2.3.1: |
Initial Implementation-Data Management System.References / 2.3.2: |
An Overview of Incident Causation Theories / 3: |
Stages of a Process-Related Incident / 3.1: |
Three Phases of Process-Related Incidents / 3.1.1: |
The Importance of Latent Failures / 3.1.2: |
Theories of Incident Causation / 3.2: |
Domino Theory of Causation / 3.2.1: |
System Theory / 3.2.2: |
Hazard-Barrier-Target Theory / 3.2.3: |
Investigation's Place in Controlling Risk / 3.3: |
Relationship between Near Misses and Incidents / 3.4: |
Endnotes |
An Overview of Investigation Methodologies / 4: |
Historical Approach / 4.1: |
Modern Structured Approach / 4.2: |
Methodologies Used by CCPS Members / 4.3: |
Description of Tools / 4.4: |
Brainstorming / 4.4.1: |
Timelines / 4.4.2: |
Sequence Diagrams / 4.4.3: |
Causal Factor Identification / 4.4.4: |
Checklists / 4.4.5: |
Predefined Trees / 4.4.6: |
Team-Developed Logic Trees / 4.4.7: |
Selecting an Appropriate Methodology / 4.5: |
Reporting and Investigating Near Misses / 5: |
Defining a Near Miss / 5.1: |
Obstacle to Near Miss Reporting and Recommended Solutions / 5.2: |
Fear of Disciplinary Action / 5.2.1: |
Fear of Embarrassment / 5.2.2: |
Lack of Understanding: Near Miss versus Nonincident / 5.2.3: |
Lack of Management Commitment and Folow-through / 5.2.4: |
High Level of Effort to Report and Investigate / 5.2.5: |
Disincentives for Reporting Near Misses / 5.2.6: |
Not Knowing Which Investigation System to Use / 5.2.7: |
Legal Aspects / 5.3: |
The Impact of Human Factors / 6: |
Defining Human Factors / 6.1: |
Human Factors Concepts / 6.2: |
Skills-Rules-Knowledge Model / 6.2.1: |
Human Behavior / 6.2.2: |
Incorporating Human Factors into the Incident Investigation Process / 6.3: |
Finding the Causes / 6.3.1: |
How an Incident Evolves / 6.4: |
Organizational Factors / 6.4.1: |
Unsafe Supervision / 6.4.2: |
Preconditions for Unsafe Acts / 6.4.3: |
Unsafe Acts / 6.4.4: |
Checklists and Flowcharts / 6.5: |
Building and Leading an Incident Investigation Team / 7: |
Team Approach / 7.1: |
Advantage of the Team Approach / 7.2: |
Leading a Process Safety Incident Investigation Team / 7.3: |
Potential Team Composition / 7.4: |
Training Potential Team Members and Support Personnel / 7.5: |
Building a Team for a Specific Incident / 7.6: |
Minor Incidents / 7.6.1: |
Limited Impact Incidents / 7.6.2: |
Significant Incidents / 7.6.3: |
High Potential Incidents / 7.6.4: |
Catastrophic Incidents / 7.6.5: |
Developing a Specific Investigation Plan / 7.7: |
Team Operations / 7.8: |
Setting Criteria for Resuming Normal Operations / 7.9: |