U.S. Department of Transportation
Date of this Version
2002
Abstract
Two kinds of bad event
Two ways of looking at human factors problems
Individual & organizational ax have different causal sets
The ‘Swiss cheese’ model of accident causation
How and why defenses fail
Matrix for defensive failures
Piper Alpha: Defensive failures
Unsafe acts
Rule-related behaviours
Workplace factors
Organizational factors
Accident investigation steps
System contributions (Single or multiple events)
Aims of HF event analysis
Comments
Proceedings of the 2nd International Workshop On Human Factors In Offshore Operations '02. Huston, Texas, April 8-10, 2002.