Preface |
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xvii | |
Abbreviations |
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xix | |
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1 Safety Culture Concepts |
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1 | (60) |
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1 | (1) |
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2 | (2) |
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1.2 Safety and Health Pioneers |
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4 | (1) |
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1.3 The Evolution of Accident Causation Models |
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5 | (8) |
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1.4 Safety and Common Sense |
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13 | (1) |
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1.5 Interviews with Safety Professionals |
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14 | (45) |
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59 | (2) |
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59 | (2) |
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2 History of Safety Culture |
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61 | (58) |
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2.1 Life Expectancy and Safety |
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61 | (4) |
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2.2 Consumer Items and Toys |
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65 | (4) |
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2.2.1 Vintage Toys and Other Items |
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66 | (3) |
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69 | (1) |
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69 | (1) |
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2.5 Off-Highway-Vehicle-Related Fatalities Reported |
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70 | (1) |
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71 | (4) |
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75 | (5) |
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2.7.1 Food Trends and Culture |
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78 | (1) |
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78 | (1) |
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78 | (2) |
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2.8 Genetically Modified Organisms (GMO) Foods |
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80 | (3) |
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2.8.1 Messenger Ribonucleic Acid (mRNA) Vaccines |
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82 | (1) |
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83 | (3) |
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2.10 Public Acceptance of Seatbelts and Masks for Protection from Respiratory Disease |
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86 | (4) |
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2.11 Radiation Hazards and Safety |
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90 | (13) |
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91 | (2) |
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2.11.2 Measuring Radiation (CDC 2021) |
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93 | (2) |
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2.11.3 Health Effects of Radiation (EPA 2021) |
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95 | (2) |
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2.11.4 Uses of Radiation (NRC 2020) |
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97 | (1) |
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97 | (1) |
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2.11.6 Academic and Scientific Applications |
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98 | (1) |
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98 | (2) |
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2.11.8 Nuclear Power Plants |
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100 | (1) |
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2.11.9 Misuse of Radiation (EPA 2021) |
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101 | (1) |
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2.11.10 Radium Dial Painters |
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101 | (2) |
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2.11.11 Safety Culture Issues |
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103 | (1) |
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2.12 The Occupational Safety and Health Administration (OSHA) |
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103 | (8) |
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2.12.1 Who Does OSHA Cover |
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105 | (1) |
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2.12.1.1 Private Sector Workers |
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105 | (1) |
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2.12.1.2 State and Local Government Workers |
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105 | (1) |
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2.12.1.3 Federal Government Workers |
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106 | (1) |
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2.12.1.4 Not Covered Under the OSHA Act |
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106 | (1) |
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2.12.2 Voluntary Protection Program |
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107 | (4) |
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2.13 Human Performance Improvement (HPI) |
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111 | (1) |
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111 | (8) |
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111 | (8) |
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119 | (1) |
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119 | (1) |
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3.1 Process Safety Management |
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119 | (1) |
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119 | (2) |
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3.1.2 Process Safety Management |
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121 | (2) |
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3.1.2.1 Process Safety Information |
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123 | (3) |
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3.1.2.2 Process Hazards Analysis |
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126 | (3) |
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3.1.2.3 Operating Procedures |
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129 | (2) |
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3.1.2.4 Mechanical Integrity |
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131 | (5) |
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3.1.2.5 Management of Change |
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136 | (2) |
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3.2 DuPont La Porte, TX, Methyl Mercaptan Release -- November 15, 2014 |
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138 | (25) |
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3.2.1 Accident Description and Analysis |
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139 | (21) |
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3.2.2 DuPont's Initiation of Process Safety Culture Assessments |
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160 | (2) |
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3.2.3 Summary of Safety Culture Findings |
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162 | (1) |
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3.3 BP Texas City Refinery Explosion -- March 23, 2005 |
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163 | (12) |
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163 | (1) |
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164 | (1) |
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3.3.3 Description of the BP Refinery |
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165 | (2) |
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167 | (6) |
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3.3.5 Trailer Siting Recommendations |
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173 | (1) |
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3.3.6 Blowdown Drum and Stack Recommendations |
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174 | (1) |
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3.3.7 Additional Recommendations from July 28, 2005, Incident |
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174 | (1) |
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3.3.8 Summary of Safety Culture Issues |
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174 | (1) |
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3.4 T2 Laboratories, Inc. Explosion -- December 19, 2007 |
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175 | (11) |
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3.4.1 T2 Laboratories, Inc. |
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175 | (1) |
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176 | (1) |
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3.4.3 Events Leading Up to the Explosion |
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176 | (4) |
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3.4.4 Analysis of the Accident |
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180 | (3) |
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3.4.5 Process Development |
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183 | (1) |
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3.4.6 Manufacturing Process |
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184 | (1) |
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3.4.7 Summary Safety Culture Issues |
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185 | (1) |
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3.5 Final Thoughts for This Chapter |
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186 | (3) |
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186 | (3) |
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4 Chemical Storage Explosions |
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189 | (30) |
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189 | (1) |
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4.1 Port of Lebanon -- August 4, 2020 |
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190 | (13) |
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4.1.1 PEPCON Explosion -- May 4, 1988 |
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191 | (10) |
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201 | (2) |
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4.1.3 Safety Culture Issues |
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203 | (1) |
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4.2 PCA DeRidder Paper Mill Gas System Explosion, DeRidder, Louisiana -- February 8, 2017 |
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203 | (8) |
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205 | (1) |
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205 | (5) |
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4.2.3 Safety Culture Summary |
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210 | (1) |
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4.3 West Fertilizer Explosion -- April 17, 2013 |
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211 | (8) |
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4.3.1 The Fire and Explosion |
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212 | (3) |
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4.3.2 Injuries and Fatalities |
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215 | (1) |
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4.3.3 Safety Culture Summary |
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215 | (1) |
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216 | (3) |
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5 Dust Explosions and Entertainment Venue Case Studies |
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219 | (54) |
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219 | (2) |
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5.1 Dust Explosion Information and Case Studies |
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221 | (4) |
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5.2 AL Solutions December 9, 2010 |
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225 | (14) |
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5.2.1 Facility Description |
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225 | (3) |
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228 | (1) |
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5.2.3 Description of the Incident |
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228 | (3) |
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5.2.4 The Origin of the Explosion |
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231 | (3) |
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5.2.5 AL Solutions Dust Management Practices |
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234 | (1) |
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5.2.6 Water Deluge System |
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235 | (1) |
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235 | (2) |
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237 | (1) |
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5.2.9 Previous Fires And Explosions |
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237 | (2) |
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5.2.10 Summary of Safety Culture Findings |
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239 | (1) |
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5.3 Imperial Sugar Company, February 7, 2008 |
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239 | (28) |
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239 | (1) |
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5.3.2 Accident Description |
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240 | (1) |
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240 | (2) |
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5.3.4 Detailed Accident Scenario |
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242 | (1) |
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5.3.5 The Chemical Safety Board Investigation |
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243 | (5) |
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5.3.6 South Packing Building |
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248 | (1) |
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5.3.7 Sugar Spillage and Dust Control |
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249 | (1) |
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5.3.8 Force of the Explosion |
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250 | (1) |
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5.3.9 Pre-explosion Sugar Dust Incident History |
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251 | (1) |
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5.3.10 Steel Belt Conveyor Modifications |
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251 | (1) |
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5.3.11 Primary Event Location |
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252 | (1) |
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5.3.12 Primary Event Combustible Dust Source |
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253 | (2) |
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5.3.13 Secondary Dust Explosions |
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255 | (1) |
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256 | (1) |
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5.3.15 Open Flames and Hot Surfaces |
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256 | (1) |
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5.3.16 Ignition Sources Inside the Steel Belt Enclosure |
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257 | (1) |
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5.3.16.1 Hot Surface Ignition |
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257 | (1) |
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258 | (1) |
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258 | (1) |
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5.3.17 Evacuation, Fire Alarms, and Fire Suppression |
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259 | (1) |
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5.3.18 Electrical Systems Design |
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260 | (1) |
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5.3.19 Sugar Dust Handling Equipment |
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261 | (1) |
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5.3.20 Housekeeping and Dust Control |
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262 | (1) |
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5.3.21 Imperial Sugar Management and Workers |
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263 | (2) |
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5.3.22 Chemical Safety Board Key Findings |
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265 | (1) |
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5.3.23 Summary of Safety Culture Findings |
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266 | (1) |
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5.4 Entertainment Venue Case Studies |
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267 | (3) |
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267 | (1) |
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267 | (1) |
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5.4.3 Fires at Bars and Nightclubs |
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267 | (1) |
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5.4.4 The New Taipei Water Park Fire -- June 2015 |
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268 | (2) |
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5.5 Safety Culture Summary |
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270 | (3) |
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270 | (3) |
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6 University Laboratory Accident Case Studies |
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273 | (42) |
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273 | (1) |
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6.1 My Experience at Aalto University |
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273 | (11) |
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6.2 Texas Tech University October 2008 |
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284 | (16) |
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6.2.1 Specifically, the CSB Found |
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299 | (1) |
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6.3 University of California Los Angeles -- December 29, 2008 |
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300 | (2) |
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6.4 University of Utah -- July 2017 |
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302 | (4) |
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6.4.1 Utah, Report to the Utah Legislature Number 2019-06 |
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302 | (4) |
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6.5 University of Hawaii -- March 16, 2016 |
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306 | (9) |
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6.5.1 Grounding (OSHA 2021) |
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307 | (1) |
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6.5.1.1 Summary of Grounding Requirements |
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308 | (1) |
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6.5.1.2 Methods of Grounding Equipment |
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308 | (1) |
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6.5.1.3 Event Description |
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309 | (2) |
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6.5.1.4 Summary of Safety Culture Issues |
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311 | (1) |
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312 | (3) |
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315 | (90) |
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315 | (22) |
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337 | (18) |
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7.1.1 Liberty Helicopter Crash March 11, 2018 |
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338 | (1) |
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338 | (8) |
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7.1.1.2 Liberty Helicopter's Safety Program |
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346 | (8) |
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7.1.1.3 Safety Culture Summary |
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354 | (1) |
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355 | (15) |
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7.2.1 Successful Landing of Crippled Commercial Airliners |
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355 | (1) |
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7.2.2 Gimli Glider -- Successful Landing of a Crippled Commercial Airliner 1 -- July 23, 1983 |
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356 | (1) |
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7.2.2.1 Accident Information |
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356 | (6) |
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7.2.2.2 Analysis of the Fuel Problem |
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362 | (8) |
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7.3 Illegal Dispatch Contrary to the MEL: Taking Off With Blank Fuel Gauges |
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370 | (3) |
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7.4 Summary of Safety Culture Issues |
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373 | (1) |
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7.5 Miracle on the Hudson River -- Successful Landing of a Crippled Commercial Airliner 2, January 15, 2009 |
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374 | (12) |
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7.5.1 Accident Information |
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374 | (3) |
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7.5.2 Flight Crew and Cabin Crew |
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377 | (2) |
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7.5.3 The Captain's 72-Hour History |
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379 | (1) |
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380 | (1) |
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7.5.4.1 The First Officer's 72-Hour History |
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380 | (1) |
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7.5.4.2 The Flight Attendants |
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381 | (1) |
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381 | (1) |
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7.5.4.4 Operational Factors |
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382 | (2) |
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7.5.4.5 Flight Crew Training |
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384 | (1) |
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7.5.4.6 Dual-Engine Failure Training |
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385 | (1) |
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7.5.4.7 Ditching Training |
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386 | (3) |
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7.5.4.8 CRM and TEM Training |
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387 | (1) |
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388 | (1) |
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7.5.4.10 Summary of Safety Culture Issues |
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389 | (1) |
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389 | (11) |
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389 | (1) |
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7.6.2 737 MAX Design and Manufacture |
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390 | (1) |
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391 | (2) |
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7.6.4 Design Certification of the 737 MAX 8 and Safety Assessment of the MCAS |
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393 | (2) |
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7.6.5 Assumptions about Pilot Recognition and Response in the Safety Assessment |
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395 | (5) |
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400 | (1) |
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7.8 Summary of Safety Culture Issues |
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401 | (4) |
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401 | (4) |
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8 Nuclear Energy Case Studies |
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405 | (80) |
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405 | (1) |
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405 | (25) |
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8.1.1 Sodium Cooled Reactors |
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409 | (1) |
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8.1.1.1 Santa Susana -- 1959 |
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410 | (1) |
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8.1.1.2 Fission Gas Release |
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411 | (2) |
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8.1.1.3 Fermi 1 -- Near Detroit Michigan -- 1966 |
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413 | (1) |
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8.1.1.4 Safety Culture Summary of Sodium Cooled Reactors |
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414 | (1) |
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8.1.2 The Vladimir Lenin Nuclear Power Plant or Chernobyl Nuclear Power Plant (ChNPP) -- April 26, 1986 |
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415 | (1) |
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8.1.2.1 Reactivity and Power Control |
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416 | (2) |
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8.1.2.2 Chernobyl Accident |
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418 | (3) |
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8.1.3 Three Mile Island Accident -- March 28, 1979 (NRC 2022a) |
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421 | (1) |
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421 | (1) |
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8.1.3.2 Summary of Events |
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422 | (3) |
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425 | (1) |
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8.1.3.4 Impact of the Accident |
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425 | (1) |
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426 | (1) |
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8.1.3.6 Human Factor Engineering Findings (Malone et al. 1980) |
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427 | (1) |
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8.1.3.7 Human Engineering and Human Error |
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428 | (1) |
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428 | (2) |
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430 | (12) |
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8.2.1 Mayak Production Association, 10 December 1968 (LANL 2000) |
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430 | (5) |
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8.2.1.1 Safety Culture Issues |
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435 | (1) |
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8.2.2 National Reactor Testing Station-January 3, 1961 (LANL 2000) |
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436 | (1) |
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8.2.2.1 Safety Culture Issues |
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437 | (1) |
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8.2.3 JCO Fuel Fabrication Plant -- September 30, 1999 (LANL 2000) |
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438 | (3) |
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8.2.3.1 Safety Culture Issues |
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441 | (1) |
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8.3 Medical Misadministration of Radioisotopes Events |
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442 | (34) |
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8.3.1 Loss of Iridium-192 Source at the Indiana Regional Cancer Center (IRCC) -- November 1992 |
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444 | (1) |
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444 | (1) |
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8.3.1.2 Event Description |
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444 | (1) |
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8.3.1.3 Patient Treatment Plan |
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444 | (11) |
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8.3.2 Greater Pittsburgh Cancer Center Incident |
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455 | (1) |
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8.3.3 Omnitron High Dose Rate (HDR) Remote Afterloader System |
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456 | (1) |
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8.3.3.1 Description of the Afterloader System |
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456 | (1) |
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8.3.3.2 High Dose Rate Afterloader |
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456 | (5) |
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461 | (1) |
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8.3.3.4 Door Status Panel |
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461 | (1) |
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8.3.3.5 Afterloader System Safety Features |
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462 | (1) |
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8.3.3.6 Patient Applicators and Treatment Tubes |
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462 | (1) |
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8.3.3.7 Description of the Source Wire |
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462 | (2) |
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8.3.3.8 Prototype Testing Performed on Nickel-Titanium Source Wire |
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464 | (1) |
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8.3.3.9 Description of the Omnitron 2000 Afterloader System Software |
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464 | (4) |
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8.3.3.10 Equipment Performance |
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468 | (1) |
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8.3.3.11 Failure Analysis Pertaining to the Source Wire |
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468 | (1) |
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8.3.3.12 Possible Failure Areas |
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468 | (1) |
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8.3.3.13 Organization of Oncology Services Corporation |
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469 | (1) |
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8.3.3.14 Management Oversight |
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469 | (1) |
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470 | (4) |
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8.3.3.16 Emergency Operating Procedures |
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474 | (1) |
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474 | (1) |
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8.3.3.18 Radiation Safety Training at the Indiana Regional Cancer Center |
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475 | (1) |
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8.3.3.19 Summary of Safety Culture Issues |
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476 | (1) |
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8.4 Goiania, Brazil Teletherapy Machine Incident (IAEA 1988) |
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476 | (9) |
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8.4.1 Safety Culture Summary |
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481 | (1) |
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481 | (4) |
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9 Other Transportation Case Studies |
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485 | (122) |
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9.1 Large Marine Vessel Accidents |
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485 | (18) |
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9.1.1 LNG Carrier Collision with Barge |
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485 | (2) |
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9.1.1.1 Accident Description |
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487 | (12) |
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9.1.1.2 Work/Rest of Ships' Crews |
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499 | (2) |
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9.1.1.3 Drug and Alcohol Testing |
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501 | (1) |
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502 | (1) |
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9.2 Navy Vessel Collisions |
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503 | (45) |
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9.2.1 USS FITZGERALD Collided with the Motor Vessel ACX Crystal |
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503 | (1) |
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9.2.1.1 Summary of Findings |
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504 | (1) |
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505 | (1) |
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9.2.1.3 Events Leading to the Collision |
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506 | (1) |
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507 | (7) |
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9.2.1.5 Impact to Berthing 2 |
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514 | (5) |
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519 | (1) |
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520 | (1) |
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9.2.1.8 Seamanship and Navigation |
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520 | (1) |
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9.2.1.9 Leadership and Culture |
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520 | (1) |
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521 | (1) |
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9.2.1.11 Timeline of Events |
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521 | (3) |
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9.2.2 Collision of USS JOHN'S MCCAIN with Motor Vessel ALNIC MC |
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524 | (1) |
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524 | (1) |
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9.2.2.2 Summary of Findings |
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525 | (1) |
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525 | (2) |
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9.2.2.4 Events Leading to the Collision |
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527 | (3) |
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9.2.2.5 Results of Collision |
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530 | (3) |
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9.2.2.6 Impact to Berthing 5 |
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533 | (3) |
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9.2.2.7 Impact on Berthing 3 |
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536 | (3) |
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9.2.2.8 Impact on Berthings 4, 6, and 7 |
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539 | (3) |
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542 | (1) |
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542 | (1) |
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9.2.2.11 Seamanship and Navigation |
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543 | (1) |
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9.2.2.12 Leadership and Culture |
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543 | (1) |
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9.2.2.13 Timeline of Events |
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544 | (4) |
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9.2.2.14 Summary of Safety Culture Issues |
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548 | (1) |
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9.3 Stretch Duck 7 July 19, 2018 |
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548 | (5) |
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548 | (1) |
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9.3.2 Accident Description |
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549 | (3) |
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9.3.3 1999 Sinking of Miss Majestic |
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552 | (1) |
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9.3 A Types of DUKW Amphibious Vessels |
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553 | (8) |
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9.3.5 NTSB Identified Safety Issue No. 1: Providing Reserve Buoyancy |
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556 | (1) |
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9.3.6 Safety Issue No. 2: Removing Canopies and Side Curtains |
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557 | (3) |
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9.3.7 Findings and Conclusions |
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560 | (1) |
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9.3.8 Safety Culture Summary Findings |
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560 | (1) |
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560 | (1) |
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9.3.9.1 Minnow, Milwaukee Harbor, Lake Michigan, September 18, 2000 |
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560 | (1) |
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9.3.9.2 DUKW No. 1, Lake Union, Seattle, Washington, December 8, 2001 |
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561 | (1) |
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9.3.9.3 DUKW34, Delaware River, Philadelphia, Pennsylvania, July 7, 2010 |
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561 | (1) |
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9.3.9.4 DUCK 6, Seattle, Washington, September 24, 2015 |
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561 | (1) |
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9.4 Recent Railroad Accidents |
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561 | (46) |
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9.4.1 AMTRAK Passenger Train -- May 12, 2015 |
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562 | (1) |
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9.4.1.1 Accident Scenario |
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562 | (3) |
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565 | (1) |
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9.4.1.3 Analysis of the Engineer's Actions |
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566 | (3) |
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9.4.1.4 Loss of Situational Awareness |
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569 | (3) |
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572 | (1) |
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9.4.1.6 Factors Not Contributing to This Accident |
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572 | (2) |
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9.4.1.7 NTSB Probable Cause |
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574 | (1) |
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9.4.1.8 Summary of Safety Culture Issues |
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574 | (1) |
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9.4.2 Transportation Safety Board of Canada (2013a) |
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574 | (4) |
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9.4.2.1 Personnel Information |
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578 | (5) |
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583 | (3) |
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586 | (1) |
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9.4.2.4 Rules and Instructions on Securing Equipment |
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587 | (3) |
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9.4.2.5 Locomotive Event Recorder |
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590 | (2) |
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9.4.2.6 Sense and Braking Unit |
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592 | (1) |
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9.4.2.7 Mandatory Off-Duty Times for Operating Employees |
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592 | (1) |
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9.4.2.8 Securement of Trains (MMA-002) at Nantes |
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592 | (1) |
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9.4.2.9 Securement of Trains (MMA-001) at Vachon |
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593 | (1) |
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9.4.2.10 Recent Runaway Train History at Montreal, Maine, and Atlantic Railway and Previous TSB Investigations |
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593 | (1) |
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9.4.2.11 Training and Requalification of Montreal, Maine, and Atlantic Railway Crews in Farnham |
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594 | (1) |
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9.4.2.12 Training and Requalification of the Locomotive Engineer |
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595 | (1) |
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9.4.2.13 Operational Tests and Inspections at Montreal, Maine, and Atlantic Railway |
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595 | (2) |
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9.4.2.14 Implementation of Single-Person Train Operations |
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597 | (2) |
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9.4.2.15 Canadian Railway Operating Rules (CROR) |
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599 | (1) |
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9.4.2.16 Single-Person Train Operations at Montreal, Maine, and Atlantic Railway |
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599 | (2) |
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9.4.2.17 Review of the Montreal, Maine, and Atlantic Railway Submission and its Relation to the Requirements of Standard CSA Q850 |
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601 | (1) |
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9.4.2.18 Research into Single-Person Train Operations |
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602 | (1) |
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603 | (1) |
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9.4.2.20 Summary of Safety Culture Issues |
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604 | (1) |
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604 | (3) |
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10 Assessing Safety Culture |
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607 | (27) |
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607 | (1) |
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10.1 Survey Research Principles |
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608 | (12) |
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10.1.1 Developing the Survey Instrument |
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609 | (1) |
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10.1.1.1 Developing the Questions/Statements |
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609 | (2) |
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10.1.1.2 Question/Statement Development |
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611 | (1) |
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612 | (1) |
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612 | (1) |
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613 | (1) |
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10.1.1.6 Analyzing the Results and Reports |
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613 | (1) |
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10.1.1.7 Final Thoughts on Developing and Delivering Surveys |
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614 | (1) |
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10.1.2 Safety Culture Assessment Methods |
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614 | (1) |
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10.1.2.1 DuPont (DuPont) De Nemours Sustainable Solutions (DSS) |
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614 | (1) |
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10.1.2.2 Department of Energy Assessment of Safety Culture Sustainment Processes |
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615 | (2) |
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10.1.2.3 Institute for Nuclear Power Operations Safety Culture Assessment |
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617 | (2) |
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10.1.2.4 Developing Team Findings |
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619 | (1) |
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10.1.3 United States Air Force Assessment Tool |
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619 | (1) |
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10.2 Assessing Health Care Safety Culture |
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620 | (1) |
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10.3 Seven Steps to Assess Safety Culture |
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621 | (13) |
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10.3.1 A Framework for Assessing Safety Culture |
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623 | (1) |
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10.3.2 Agency for Healthcare Research and Quality |
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623 | (1) |
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10.3.3 Graduate Student Safety Culture Survey |
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623 | (3) |
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10.3.4 Idaho National Engineering Laboratory Survey |
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|
626 | (8) |
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|
634 | (1) |
References |
|
634 | (3) |
Index |
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637 | |