Columbia Crew Survival Investigation Report


Book Description

NASA commissioned the Columbia Accident Investigation Board (CAIB) to conduct a thorough review of both the technical and the organizational causes of the loss of the Space Shuttle Columbia and her crew on February 1, 2003. The accident investigation that followed determined that a large piece of insulating foam from Columbia's external tank (ET) had come off during ascent and struck the leading edge of the left wing, causing critical damage. The damage was undetected during the mission. The Columbia accident was not survivable. After the Columbia Accident Investigation Board (CAIB) investigation regarding the cause of the accident was completed, further consideration produced the question of whether there were lessons to be learned about how to improve crew survival in the future. This investigation was performed with the belief that a comprehensive, respectful investigation could provide knowledge that can protect future crews in the worldwide community of human space flight. Additionally, in the course of the investigation, several areas of research were identified that could improve our understanding of both nominal space flight and future spacecraft accidents. This report is the first comprehensive, publicly available accident investigation report addressing crew survival for a human spacecraft mishap, and it provides key information for future crew survival investigations. The results of this investigation are intended to add meaning to the sacrifice of the crew's lives by making space flight safer for all future generations.







Patient Safety


Book Description

The second edition of this well-received book, the first to provide detailed guidance on how to conduct incident investigations in primary care, has been thoroughly revised and updated throughout to reflect the current nomenclature for different aspects of the investigatory process in the UK and the latest format for incident reporting. Key features: Explains how to recognise a serious clinical incident, how to conduct a root cause analysis (RCA) investigation, and how and when duty of candour applies Covers the technical aspects of serious incident recognition and report writing Includes a wealth of practical advice and 'top tips', including how to manage the common pitfalls in writing reports Offers practical advice as well as some new and innovative tools to help make the RCA process easier to follow Explores the all-important human factors in clinical incidents in detail, with multiple examples and worked-through cases studies as well as in-depth sample reports and analysis. At a time of increasing regulatory scrutiny and medico-legal risk, in which failure to manage appropriately can have serious consequences both for service organisations and for individuals involved, this concise and convenient book continues to provide a master class for anyone performing RCA and aiming to demonstrate learning and service improvement in response to serious clinical incidents. It is essential reading for any clinical or governance leads in primary care, including GP practices, 'out-of-hours', urgent care centres, prison health and NHS 111. It also offers valuable insights to any clinician who is in training or working at the coal face who wishes to understand how serious clinical incidents are investigated and managed.




Root Cause Analysis Handbook


Book Description

Are you trying to improve performance, but find that the same problems keep getting in the way? Safety, health, environmental quality, reliability, production, and security are at stake. You need the long-term planning that will keep the same issues from recurring. Root Cause Analysis Handbook: A Guide to Effective Incident Investigation is a powerful tool that gives you a detailed step-by-step process for learning from experience. Reach for this handbook any time you need field-tested advice for investigating, categorizing, reporting and trending, and ultimately eliminating the root causes of incidents. It includes step-by-step instructions, checklists, and forms for performing an analysis and enables users to effectively incorporate the methodology and apply it to a variety of situations. Using the structured techniques in the Root Cause Analysis Handbook, you will: Understand why root causes are important. Identify and define inherent problems. Collect data for problem-solving. Analyze data for root causes. Generate practical recommendations. The third edition of this global classic is the most comprehensive, all-in-one package of book, downloadable resources, color-coded RCA map, and licensed access to online resources currently available for Root Cause Analysis (RCA). Called by users "the best resource on the subject" and "in a league of its own." Based on globally successful, proprietary methodology developed by ABS Consulting, an international firm with 50 years' experience in 35 countries. Root Cause Analysis Handbook is widely used in corporate training programs and college courses all over the world. If you are responsible for quality, reliability, safety, and/or risk management, you'll want this comprehensive and practical resource at your fingertips. The book has also been selected by the American Society for Quality (ASQ) and the Risk and Insurance Society (RIMS) as a "must have" for their members.







Air Force AFM.


Book Description




Occupational Health and Safety in Construction Project Management


Book Description

This book addresses an increasingly important area in the construction industry. Case studies are used extensively to illustrate important points and refer to current successful safety management techniques.




Principles of Construction Safety


Book Description

The construction industry has not had a good record on health and safety and faces tough legal and financial penalties for breaches of the law. This book provides a unique resource for all those who construct or procure the construction of projects of all sizes and in all countries and for clients who need to keep abreast of their own and their contractors' responsibilities. It gives practical guidance on best practice, including: measuring performance and recording information developing a safety policy and method statements assessing risk training and understanding people the basics of the construction/environment interface The book addresses several topics not found in other reference works, discussing techniques of health and safety and basic environmental management as applied to the industry. It uniquely provides 50 quick reference guides setting out solutions to common problems. These include falls, manual and mechanical handling, work with asbestos and noise. It also summarises the main UK legal requirements on construction safety and health and includes a number of useful checklists and model forms. Written by a very experienced health and safety practitioner, who is also author of the highly successful IOSH book Principles of Health and Safety at Work, this book will be welcomed by all responsible for health and safety. It will also provide an excellent text for the NEBOSH (National Examination Board in Occupational Safety and Health) Construction Safety and Health national certificate.




Incident Investigation and Accident Prevention in the Process and Allied Industries


Book Description

To prevent future accidents, a complete examination of the causes and contributory factors of an accident is necessary. Stressing the need to correct these issues, Incident Investigation and Accident Prevention in the Process and Allied Industries strikes a balance between the theoretical and applied aspects of accident investigation while also addressing accident prevention. Based on the authors forty years of experience, this detailed work covers an extensive range of topics often encountered during an incident investigation. Since the scope and needs of investigations can widely vary, the author begins with an introduction that provides guidance on how to use the book. He supplies a "roadmap" of incident investigation, making the material accessible to novices yet also valuable to more seasoned investigators. Topics include: Responding to occurrence of incidents and emergency response Securing the site and handling eyewitness testimonies Notification of appropriate authorities, compliance requirements, and legal and insurance issues Internal/external incident investigation options and investigation team requirements Disassembly, gathering, screening, tagging, storing of evidence, and post-incident testing Establishing preliminary causal mechanisms and root cause determinations Multiple cause determination, incident modeling, and human error evaluation and reporting Remedial and preventative measures, lessons learned, and reconstruction and retraining Accident prevention through predictive methodologies, including pro-active measures Pre- and post-incident management Corporate structuring, attitudinal problems, and planning an accident prevention program




Near-Miss Book


Book Description