Detailed event analysis is a systematic, organised approach to analysing the elements that led to the accident, in order to draw conclusions concerning its causes, development, and consequences. It constitutes a mine of knowledge and experience for defining measures for correcting the situation in the long-term.
Indeed, the challenge of in-depth event analyses is to understand, in order to act, which implies:
- Going beyond the obvious causes, human error and equipment malfunction, to identify the root causes,
- Sharing the analyses to raise awareness of the mechanics of technical, human and organisational failures.
This Cahier de la sécurité industrielle presents the challenges and all of the steps in a detailed event analysis, an "analyst's toolbox" and a panorama of the existing analysis methods.
Objectives
To present the benchmarks and methods necessary to implement more efficient analysis conditions, integrating the human and organisational dimension.
About the authors
This Report is the fruit of 3 years of reflection by the "Improving the incident analysis process " working group, led by Myriam Promé-Visinoni (Icsi). Total, SNCF, EDF, Solvay-Rhodia, Air Liquide, CFDT Chimie Energie, Areva and Foncsi have pooled their experience to produce this guide.