Anatomy of an incident

Journal Article · Wed Mar 23 00:00:00 EDT 2016 · Journal of Chemical Health and Safety

DOI:https://doi.org/10.1016/j.jchas.2016.02.006· OSTI ID:1258579

Cournoyer, Michael E. ^[1]; Trujillo, Stanley ^[1]; Lawton, Cindy M. ^[1]; Land, Whitney M. ^[1]; Schreiber, Stephen B. ^[1]

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1. Los Alamos National Lab. (LANL), Los Alamos, NM (United States)

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 failure – trouble 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. We analyzed the contributing factors that caused a radiological incident. When 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.

• Research Organization: Los Alamos National Laboratory (LANL), Los Alamos, NM (United States)
• Sponsoring Organization: USDOE
• Grant/Contract Number: AC52-06NA25396
• OSTI ID: 1258579
• Alternate ID(s): OSTI ID: 1410749
• Report Number(s): LA-UR-16-20955; PII: S1871553216300123
• Journal Information: Journal of Chemical Health and Safety, Journal Name: Journal of Chemical Health and Safety; ISSN 1871-5532
• Publisher: Elsevier
• Country of Publication: United States
• Language: English

Related Subjects

99 GENERAL AND MISCELLANEOUS
61 RADIATION PROTECTION AND DOSIMETRY
Incident
Human Error
Apparent Cause
Process Improvement
Radiological