Review article
Integrated safety investigation methodology (ISIM) - a systematic approach to accident prevention by transportation safety board of Canada
Marcel Ayeko
; Transportation Safety Board (TSB) of Canada
Abstract
During the past seven years (1990-1998), the Transportation Safety Board (TSB) of Canada, had investigated over 750 marine accidents and incidents (occurrences).
The analyses of these occurrences show that marine accidents, just like those in other industries, are the result of multiple causes and underlying factors. In any system operation, there is a complex interaction involving machinery, equipment, humans and the environment. Human and organizational factors are implicated in most accidents as underlying of contributing factors to the immediate causes of those accidents. In order for accident prevention strategies to be effective, an accident investigation must search beyond the immediate cause. This suggests a need for a much boarder system approach a look for contributing factors to the accident and underlying Safety Deficiencies1 (SD) that pose a risk to life, property and environment. Hence, TSB developed the Integrated Safety Investigation Methodology (ISIM). The ISIM embeds the function of safety deficiency analysis into the investigation process, commencing with the assessment of the initial occurrence notification through to the effective communication of the identified risks to those who can influence the necessary change.
However, discussion in this paper is limited to the systematic evaluation of an occurrence to determine
the root causes, contributing, and underlying safety deficiencies commonly found in TSB investigations.
Keywords
Hrčak ID:
344196
URI
Publication date:
23.12.1999.
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