Anatomy of an incident
Abstract
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.
- Authors:
-
- Los Alamos National Lab. (LANL), Los Alamos, NM (United States)
- Publication Date:
- Research Org.:
- Los Alamos National Laboratory (LANL), Los Alamos, NM (United States)
- Sponsoring Org.:
- USDOE
- OSTI Identifier:
- 1258579
- Alternate Identifier(s):
- OSTI ID: 1410749
- Report Number(s):
- LA-UR-16-20955
Journal ID: ISSN 1871-5532; PII: S1871553216300123
- Grant/Contract Number:
- AC52-06NA25396
- Resource Type:
- 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
- Publisher:
- Elsevier
- Country of Publication:
- United States
- Language:
- English
- Subject:
- 99 GENERAL AND MISCELLANEOUS; 61 RADIATION PROTECTION AND DOSIMETRY; Incident; Human Error; Apparent Cause; Process Improvement; Radiological
Citation Formats
Cournoyer, Michael E., Trujillo, Stanley, Lawton, Cindy M., Land, Whitney M., and Schreiber, Stephen B. Anatomy of an incident. United States: N. p., 2016.
Web. doi:10.1016/j.jchas.2016.02.006.
Cournoyer, Michael E., Trujillo, Stanley, Lawton, Cindy M., Land, Whitney M., & Schreiber, Stephen B. Anatomy of an incident. United States. https://doi.org/10.1016/j.jchas.2016.02.006
Cournoyer, Michael E., Trujillo, Stanley, Lawton, Cindy M., Land, Whitney M., and Schreiber, Stephen B. Wed .
"Anatomy of an incident". United States. https://doi.org/10.1016/j.jchas.2016.02.006. https://www.osti.gov/servlets/purl/1258579.
@article{osti_1258579,
title = {Anatomy of an incident},
author = {Cournoyer, Michael E. and Trujillo, Stanley and Lawton, Cindy M. and Land, Whitney M. and Schreiber, Stephen B.},
abstractNote = {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.},
doi = {10.1016/j.jchas.2016.02.006},
journal = {Journal of Chemical Health and Safety},
number = ,
volume = ,
place = {United States},
year = {Wed Mar 23 00:00:00 EDT 2016},
month = {Wed Mar 23 00:00:00 EDT 2016}
}
Search WorldCat to find libraries that may hold this journalWorks referenced in this record:
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