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Title: Anatomy of an incident

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.
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  1. Los Alamos National Lab. (LANL), Los Alamos, NM (United States)
Publication Date:
Report Number(s):
Journal ID: ISSN 1871-5532; PII: S1871553216300123
Grant/Contract Number:
Accepted Manuscript
Journal Name:
Journal of Chemical Health and Safety
Additional Journal Information:
Journal Name: Journal of Chemical Health and Safety; Journal ID: ISSN 1871-5532
Research Org:
Los Alamos National Lab. (LANL), Los Alamos, NM (United States)
Sponsoring Org:
Country of Publication:
United States
99 GENERAL AND MISCELLANEOUS; 61 RADIATION PROTECTION AND DOSIMETRY; Incident; Human Error; Apparent Cause; Process Improvement; Radiological
OSTI Identifier:
Alternate Identifier(s):
OSTI ID: 1410749