3.4. Accident investigation tools

It is rather obvious that it is important to investigate the causes of an accident. Without the “what, how and why” no correction action or future prevention is possible. As we have seen, a SMS goes a step further and requires that an incident must be investigated, and this includes a near-miss event. The purpose is to learn and improve. Even better is to identify precursors such as defects, disruptions, and deviations that under perhaps slightly different conditions can initiate a cause–consequence chain to serious effect. Precursors are closely related to a failure process, and certainly when they prove to be possibly affecting the function of safety critical components and to be occurring in larger numbers, ...

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