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Accident Investigation and Analysis Methods Database
Updated through 24 Sept 2019.
Created and maintained for research use at the Investigation Process Research Resources web site
© 2019 Ludwig Benner Jr.
http://www.iprr.org/research/AI_Methods_db.pdf
Table of Contents
Abstract. 2
A. List of Acronyms for methods. 2
B. Examples of documents where methods are referenced or evaluated. 4
C. Specific URLS for individual methods: 6
D. List of acronyms With Full Names in JRC– (2011) Comparative Analysis of
Nuclear Event Investigation Methods, Tools and Techniques, Interim Technical
Report, EUR 24757 EN 9
E. Summary of differences found among investigation and analysis methods by
comparison of descriptions, application of method, or analyses of reports.
10
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ABSTRACT. This document contains a listing of acronyms for accident investigation and analysis methods presently available, examples of documents with comparisons of investigation methods, with sources, specific URLs for Internet sites where the methods are described, a list of acronyms and definitions in JRC (2011), and a list of differences found among investigation and analysis methods, identified over time by comparing descriptions of methods, reports produced by methods, and use of data produced by the methods.
The database was created initially to capture and document the new methods as they came to my attention in recent years, and is now maintained and updated for historical and research purposes as new methods are identified.
Visitors are invited to submit additional entries to me.
A. List of Acronyms for Methods.
Other methods:
ETHNOGRAPHIC method - used for D. Vaughan’s book for analyzing the Challenger accident.
DELPHI method -for developing converging opinions about a subject
EPIDEMIOLOGICAL method - used for analyzing incidents in the medical field.
EXPERIENTIAL methods used by individuals based on their life experiences.
INTUITIVE methods based on “common sense.”
1. 3CA 2. 5 WHYS 3. ACCI-MAP
4. AEB 5. APPOLO 6. ASSET
7. ATHEANA 8. CAS-HEAR 9. CASMET
10. CAST 11. ECFC 12. ETBA
13. FRAM 14. HERA
15. HFACS 16. HFIT 17. HPEP
18. HPES 19. HPIP 20. HSE256
21. ISSM 22. JAGMAN 23. MORT
24. MTO 25. OARU 26. PRCAP
27. PSA
28. RCA 29. SCAT 30. SHELL
31. SOL 32. SRM 33. STAMP
34. STEP/MES
35. TapRooT®36. TOP-SET 37. TRIPOD
38. WAIT 39. WBA
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B. Examples of Documents Where Methods Are Referenced or Evaluated. If better references to a method exists, please bring it to my attention and I will update the following list.
1. A study of accident investigation methodologies applied to the Natech events during the 2011 Great East Japan earthquake. DOI: 10.1016/j.jlp.2018.01.003 https://www.researchgate.net/publication/322388652_A_study_of_accident_investigation_methodologies_applied_to_the_Natech_events_during_the_2011_Great_East_Japan_earthquake
2. Comparison of some selected methods for accident investigation, https://pdfs.semanticscholar.org/bb88/ff5d4ce5a85832c020c2624d8d3cfcee99fa.pdf (Sklet) p 31
3. Study on Developments in Accident Investigation Methods: A Survey of the “State-of-the-Art”, http://www.iaea.org/inis/collection/NCLCollectionStore/_Public/40/012/40012565.pdf, (SKI), p 15-19
4. Towards an evaluation of accident investigation methods in terms of their alignment with accident causation models, http://www.sakellaropoulos.gr/Publications/J43_Safety%20Science_2009_47_1007-15.pdf (Pan) p 1007-1015
5. Rating Accident Models and Investigation Models, Journal of Safety Research, Vol. 16, pp. 105–126, http://www.iprr.org/theory/JSR85b.pdf (JSR)
6. Accident Models: How Underlying Differences Affect Workplace Safety, International Seminar on Occupational Accident Research, Part I, Salsjobaden Sweden, September 1983 p 173-201
6. Models for Accident Investigation. Harvey, M. J., OHS Division, Alberta Workers Health, Safety and Compensation, 1985, http://www.iprr.org/proj/harvey.html (MJH)
7. Accident analysis models and methods: guidance for safety professionals Underwood, P.J. and Waterson, P.E. 2013https://dspace.lboro.ac.uk/dspace-jspui/bitstream/2134/13865/4/Underwood%20and%20Waterson. Also see Analysis, Causality and Proof in Safety Investigations, https://www.atsb.gov.au/media/27767/ar2007053.pdf (UW)
8. An analytical evaluation of the methodological constraints and affordances of an incident investigation manual, H.Huang 2013 www.dcs.gla.ac.uk/~johnson/IFIP13.5/papers/Huang.pdf (HH)
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C. Specific URLS for Individual Methods:
1. 3CA - Control Change Cause Analysis, http://www.nri.eu.com/3ca.html (JRC) See also http://www.nri.eu.com/3ca.html
2. 5 Whys - https://www.isixsigma.com/tools-templates/cause-effect/determine-root-cause-5-whys/
3. AcciMap - https://en.wikipedia.org/wiki/AcciMap_approach (Sklet) 4. AEB - Accident Evaluation and Barrier function, (Sklet)(JRC)(SKI) 5. APPOLO- http://www.apollorootcause.com/about/apollo-root-cause-analysis-method/ 6. ASSET - Assessment of Safety Significant Event Team, https://www-pub.iaea.org/MTCD/
Publications/PDF/, (JRC) 7. ATHEANA - A Technique for Human Event Analysis https://www.nrc.gov/docs/ML0037/
ML003719212.pdf (JRC) 8. CAS-HEAR Computer-Aided System for Human Error Analysis and Reduction, http://
publications.jrc.ec.europa.eu/repository/bitstream/JRC68919/updated%20reqno_jrc68919_final_document_for_online.pdf (JRC)
9. CASMET - Casualty Analysis Methodology for Maritime OperationsCasualty Analysis Methodology for Maritime Operations, www.emsa.europa.eu/work/download/499/516/23.html (Added Feb 2019)
10.CAST - Causal Analysis using System Theory, http://psas.scripts.mit.edu/home/wp-content/uploads/2013/04/CAST_Tutorial-2013.pdf; CAST Handbook: How to Learn More from Incidents and Accidents, http://psas.scripts.mit.edu/home/get_file4.php?name=CAST_handbook.pdf
11.CREAM - Cognitive Reliability ad Error Analysis Method, https://www.elsevier.com/books/cognitive-reliability-and-error-analysis-method-cream/hollnagel/978-0-08-042848-2
12.ECFC - Events and Causal Factors Charting, https://www.osti.gov/biblio/5651580, (JRC)(SKI)
13.ETBA - Energy Trace and Barrier Analysis, http://www.nri.eu.com/PSAM-FINAL.pdf 14.FRAM - Functional Resonance Analysis Model, http://www.functionalresonance.com
(JRC)(SKI) 15.FTA - Fault tree analysis, aka Event Tree Analysis, https://en.wikipedia.org/wiki/
Fault_tree_analysis, (Sklet) 16.HERA https://www.sciencedirect.com/science/article/pii/S0951832001000990 (SKI) 17.HFACS - Human Factors Analysis and Classification System, https://www.skybrary.aero/
index.php/ (SKI) 18.HFIT - Human Factors Investigation Tool, http://www.hrdp-idrm.in/e5783/e17327/e28013/
e28958/e29007/ (JRC)(SKI) 19. HPEP - Human Performance Evaluation Process, https://www.nrc.gov/docs/ML0209/
ML020930054.pdf (JRC) 20.HPES (J-HPES) - Human Performance Enhancement System, https://slideplayer.com/
slide/10900584/ (JRC)(SKI)
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21.HPIP - Human Performance Investigation Process, http://www.iaea.org/inis/collection/NCLCollectionStore/_Public/25/032/25032075.pdf (JRC)
22.HSE256 -Health and Safety Executive (HSE) (Ed.), 2004. HSG (245) – Investigating Accidents and Incidents. HSE, UK.(Pan)
23.ISIM - Integrated Safety Investigation Methodology, https://www.skybrary.aero/index.php/Investigation_Methodology
24.JAGMAN - Judge Advocate General method, http://www.jag.navy.mil/distrib/instructions/JAGMAN_Investigations_Handbook_2015.pdf (added Feb 2019)
25.MORT -Management Oversight and Risk Tree, https://www.osti.gov/servlets/purl/5254810/ (JRC)(Sklet)
26.MTO -Man, Technology , Organization, http://www.ptil.no/getfile.php/13699/z%20Konvertert/Health%2C%20safety%20and%20environment/Safety%20and%20working%20environment/Dokumenter/mto_engl.pdf (Sklet) (JRC)
27.OARU - Occupational Accident Research Unit https://www.sciencedirect.com/science/article/abs/pii/0376634981900055 (Pan)
28.PEAT - Procedural Event Analysis Tool, https://flightsafety.org/wp-content/uploads/2016/09/PEAT_application.pdf (SKI)
29.PRCAP - Paks Root Cause Analysis Procedure, http://publications.jrc.ec.europa.eu/repository/bitstream/JRC68919/updated%20reqno_jrc68919_final_document_for_online.pdf (JRC)
30.PSA - http://nusbaumer.tripod.com/resources/publications/nusbaumer_introduction_to_probabilistic_safety_assessments.pdf (JRC)
31.RCA - Root Cause Analysis, https://en.wikipedia.org/wiki/Root_cause_analysis (JRC) 32.SCAT - Systemic Cause Analysis Technique, https://www.dnvgl.com/services/incident-
investigation-1995 (Sklet) 33.SHELL -software, hardware, environment, liveware model , https://en.wikipedia.org/wiki/
SHELL_model, International Civil Aviation Organization (1993).** //Human factors digest no 7
34.SOL - Safety through Organizational Learning, http://erg.bme.hu/sol/SOL_Williamsburg5.pdf, (Sklet) (JRC)
35. SRM Systematic Reanalysis Method www.dcs.gla.ac.uk/~johnson/IFIP13.5/papers/Huang.pdf (HH)
36.STAMP Systems Theoretical Accident Model Process, http://sunnyday.mit.edu/accidents/safetyscience-single.pdf, (SKI)
37.STEP - Simultaneous Timed Events Plotting, Investigating Accidents with STEP ISBN 0-8247-7510-4, (JRC)(Sklet) see also http://www.ludwigbenner.org/STEP-MES_Guides-wf/Guide00.html
38.TapRooT® - Root cause analysis, problem investigation, proactive improvement, https://en.wikipedia.org/wiki/Taproot
39.TOP SET - Technology, organization, people, similar events, environment, time, http://www.kelvintopset.com/about/methodology
40.TRIPOD beta - (barrier-based risk model), https://en.wikipedia.org/wiki/Tripod_Beta (Sklet)
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41.WAIT - Work accidents investigation technique Jacinto, C., Aspinwall, E., 2003. Work accidents investigation technique (WAIT) –part I. Safety Science Monitor 1 (IV-2).(p1010) https://www.researchgate.net/publication/228784335_Work_accidents_investigation_technique_WAIT-part_I (Pan)
42.WBA - Why-Because Analysis), https://en.wikipedia.org/wiki/Why–because_analysis
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D. List of Acronyms With Full Names in JRC– (2011) Comparative Analysis of Nuclear Event Investigation Methods, Tools and Techniques, Interim Technical Report, EUR 24757 EN
AEB Accident Evolution and Barrier function ASSET Assessment of Safety Significant Event Team ATHEANA A Technique for Human Event Analysis CAS-HEAR Computer-Aided System for Human Error Analysis and Reduction CCF Common Cause Failure CRT Current Reality Tree ECFC Event and Causal Factors Charting ESReDA European Safety Reliability and Data Association FRAM Functional Resonance Analysis Method HF Human Factors HFIT Human Factors Investigation Tool HOF Human or Organizational Factors HPEP Human Performance Evaluation Process HPES Human Performance Enhancement System HPIP Human Performance Investigation Process HRA Human Reliability Analysis IAEA International Atomic Energy Agency IE Initiating Event IET Institute for Energy and Transport INES International Nuclear Event Scale IRS Incident Reporting System LL LessonsLearned MORT Management Oversight and Risk Tree MTO Man, Technology, Organisation NPP Nuclear Power Plant NRC (United States) Nuclear Regulatory Commission NUSAC Nuclear Safety Clearinghouse (action of Safety of Present Nuclear Reactors Unit at IET) OEF Operating Experience Feedback PRCAP Paks Root Cause Analysis Procedure PROSPER Peer Review of the effectiveness of the Operational Safety Performance Experience Review PSA Probabilistic Safety Assessment PWR Pressurized Water Reactor RCA Root Cause Analysis SAR Safety Analysis Report SOL Safety through Organisational Learning SPNR Safety of Present Nuclear Reactors Unit at IET STEP Sequential Timed Events Plotting TSO Technical Support Organization WGOE Working Group on Operating Experience 3CA Control Change Cause Analysis
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E. Summary of Differences Found Among Investigation and Analysis Methods by Comparison of Descriptions, Application of Method, or Analyses of Reports.
1. foundational thinking This refers to the habits of thought or perceptions, constructs, and assumptions about what accidents and investigations are, which form the basis for the design of the method.
2. purpose(s) or goal(s) The reasons for doing the investigation, and what it is expected to produce.
3. scopeWhat is to be covered by the investigation, like the beginning and end of the phenomenon that will be investigated, or the reported time frame, entities involved, relationships or functions addressed?
4. “events” What does the method consider an event to be; definitions, documentation and treatment?
5. expected investigator competencies What are investigator’s knowledge, skill and tool and attitude expected to be for the implementation of the methods’ functional tasks?
6. input data criteria What qualifies for selection, documentation and organization of data used as inputs to arrive at what is included in the reported description of what happened?
7. rigor or stringency How instructive and demanding is the method for ensuring expected task performance level by investigators?
8. investigation strategy What strategy is shaping input data search, acquisition and processing during an investigation?
9. description criteria What are criteria for documenting and reporting an explanatory description of what happened?
10. input data criteria What is basis for selecting and documenting input data to include in the description of what happened and reports?
11. input data processing What are criteria for processing input data to develop report of what happened,
12.input data controls What does method provide to prevent subjective, irrelevant, assumed, corrupt or false data or contrived relationships or inappropriate characterizations in reports?
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13.data specificity To what degree are ambiguous, abstract, speculative, judgmental, characterized, pejorative, accusatory, incomplete or investigator-created content are required or acceptable in reported descriptions of what happened?
14. problem discovery and definition What is the procedure prescribed by method to determine problems exposed by the investigation?
15.report specifications What, if any, kind of form, structure, output topics and content does method specify?
16.passive voiceDoes method accept or prohibit passive voice in narrative reports or report sections describing what happened?
17.safeguards against biases Does method provide or indicate measures to minimize biases in selection, documentation, interpretation or characterrization of reporting of data. during investigations?
18.quality assurance What tests or measures does method specify or use to assure investigation report validity or logical soundness and completeness?
19.delivery timeliness Does method consider delivery timeliness of interim or completed investigation work products?
20. investigation efficiency
How efficient is investigation resources usage during the investigation process?
20.data concatenation Does method produce data in a format that can be loaded into a database without modification?
and after methods’ outputs are utilized by users, differences in the
21.utility Is the reported data useful to users, to support their analyses or subsequent response actions?
22.usage efficiency How much must users do with reported data before they can use it to satisfy their needs,
23.efficacy How much did the reported data benefit a user who used the reported data
24. toneDoes the method produce a positive, constructive or empathetic report tone, or negative, accusatory, threatening or retributive report tone.
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ADDENDA https://www.tennet.eu/fileadmin/user_upload/Company/Safety/Documents/SSC17-005_Approved_methods_for_SHE_incident_investigation.pdf
Approved methods for SHE incident investigation SSC17-005
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