Preface |
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xv | |
Acknowledgements |
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xxiii | |
Authors |
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xxv | |
Section I: Introduction |
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Chapter 1 Introducing some basic concepts |
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3 | (6) |
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Chapter 2 Framework conditions |
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9 | (10) |
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2.1 Conditions inside the company |
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9 | (4) |
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2.1.1 Size, type of technology, and resources |
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9 | (2) |
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2.1.2 The organisational context |
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11 | (2) |
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2.2 Conditions outside the organisation |
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13 | (6) |
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2.2.1 Regulatory requirements for the management of safety |
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13 | (2) |
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2.2.2 Regulations on record keeping and on reporting injuries and incidents to the authorities |
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15 | (1) |
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2.2.3 Workers' compensation systems |
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16 | (1) |
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2.2.4 International standards and guidelines |
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16 | (2) |
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2.2.5 Other non-governmental organisations |
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18 | (1) |
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19 | (6) |
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3.1 Reducing emissions into the air from a fertiliser plant |
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19 | (6) |
Section II: Theoretical foundation |
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Chapter 4 Accident theory and models |
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25 | (26) |
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4.1 On the need for accident models |
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25 | (2) |
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4.2 Causal-sequence models |
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27 | (4) |
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31 | (3) |
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34 | (4) |
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4.4.1 The Swiss cheese model |
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37 | (1) |
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38 | (1) |
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39 | (7) |
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4.6.1 Hierarchical root-cause analysis models |
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40 | (1) |
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4.6.2 Safety management models |
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40 | (5) |
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4.6.3 Systemic accident models |
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45 | (1) |
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4.7 Use of accident models in investigations of accidents and near accidents |
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46 | (1) |
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47 | (4) |
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Chapter 5 Framework for accident analysis |
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51 | (36) |
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5.1 Characteristics of the accident sequence |
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51 | (7) |
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5.2 Types of data and scales of measurement |
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58 | (1) |
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5.3 Consequences of accidents |
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59 | (9) |
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5.3.1 Types of consequences |
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59 | (1) |
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60 | (1) |
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5.3.3 Economic consequences of accidents |
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60 | (6) |
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5.3.4 Actual versus potential losses |
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66 | (2) |
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5.4 Incident (uncontrolled energy flow) |
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68 | (1) |
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69 | (3) |
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5.6 Contributing factors and root causes |
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72 | (19) |
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5.6.1 Contributing factors at the functional department and work-system levels |
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75 | (4) |
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5.6.2 Root causes at the general and HSE-management-systems levels |
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79 | (2) |
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5.6.2.1 Causes derived from quality-assurance principles |
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80 | (1) |
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5.6.3 Causes derived from safety culture elements |
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81 | (1) |
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5.6.4 Problems in identifying causal factors |
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81 | (6) |
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Chapter 6 The occurrence of accidents over time |
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87 | (4) |
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Chapter 7 Management of safety through experience feedback |
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91 | (26) |
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7.1 What is meant by experience feedback? |
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91 | (1) |
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7.2 Feedback and use of safety-related information in decision-making |
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92 | (2) |
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94 | (4) |
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7.3.1 Juran's feedback cycle for the control of anything |
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95 | (1) |
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7.3.2 The diagnostic process |
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96 | (1) |
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97 | (1) |
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7.4 Scope and level of feedback |
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98 | (6) |
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7.4.1 Ashby's law of requisite variety |
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98 | (3) |
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7.4.2 Van Court Hare's hierarchy of order of feedback |
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101 | (3) |
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7.5 Safety information systems |
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104 | (4) |
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7.5.1 Developing the model further |
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107 | (1) |
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7.6 Organisational learning |
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108 | (2) |
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7.7 Obstacles in the management of safety through experience feedback |
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110 | (4) |
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7.7.1 Limitations in human information processing |
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110 | (2) |
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7.7.2 Organisational defences |
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112 | (2) |
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7.8 Effects of experience feedback on the risk of accidents |
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114 | (3) |
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Chapter 8 Criteria for assessing the efficiency of experience feedback |
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117 | (12) |
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8.1 The feedback control cycle |
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118 | (5) |
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8.1.1 Requirements for safety performance indicators |
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119 | (1) |
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8.1.2 Requirements for the different elements of the safety performance monitoring system and the system as a whole |
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120 | (3) |
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120 | (2) |
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8.1.2.2 Distribution and presentation of information |
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122 | (1) |
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8.1.2.3 The safety performance monitoring system as a whole |
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123 | (1) |
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123 | (6) |
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8.2.1 Incident investigations |
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123 | (3) |
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8.2.1.1 Notification and initial recording |
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124 | (1) |
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124 | (1) |
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125 | (1) |
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8.2.1.4 Implementation and follow-up |
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126 | (1) |
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126 | (1) |
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8.2.2 Risk assessment process |
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126 | (3) |
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Chapter 9 Barriers against loss |
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129 | (30) |
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130 | (4) |
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9.2 Passive and active barriers |
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134 | (1) |
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135 | (2) |
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9.4 Limitations of barriers |
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137 | (5) |
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9.4.1 Quality of barriers |
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140 | (1) |
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9.4.2 Inspection, testing and maintenance of barriers |
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141 | (1) |
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9.5 Applying barriers in the prevention of occupational accidents |
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142 | (7) |
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142 | (4) |
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9.5.2 Safety against chemical hazards |
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146 | (1) |
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9.5.3 Safety in the use of cranes |
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147 | (1) |
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9.5.4 Safety in the use of heavy mobile equipment |
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148 | (1) |
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9.6 Permit-to-work system |
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149 | (3) |
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9.7 Emergency response management |
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152 | (7) |
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Chapter 10 The human element in accident control |
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159 | (18) |
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10.1 The human operator as a barrier element |
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159 | (3) |
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162 | (7) |
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10.2.1 The theory of risk homeostasis |
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166 | (1) |
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10.2.2 Successful operations and failure-free organisations |
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167 | (2) |
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10.3 Managing the human element in accident prevention |
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169 | (8) |
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10.3.1 Modification of the physical and organisational context |
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170 | (1) |
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10.3.2 Personnel-related measures |
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171 | (1) |
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10.3.3 Effectiveness of measures directed at workers |
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172 | (5) |
Section III: Learning from incidents and deviations |
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Chapter 11 Sources of data on accident risks |
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177 | (4) |
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11.1 The ideal scope of different data-collection methods |
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177 | (1) |
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11.2 Filters and barriers in data collection |
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177 | (4) |
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Chapter 12 Hazard identification, safety inspections and audits |
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181 | (20) |
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12.1 Hazard identification |
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181 | (2) |
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183 | (6) |
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12.2.1 Workplace inspections |
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184 | (3) |
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12.2.2 Management inspections |
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187 | (1) |
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12.2.3 Inspection and testing of barrier integrity |
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188 | (1) |
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189 | (12) |
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12.3.1 General guidelines for the auditing of management systems |
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190 | (6) |
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12.3.2 Example: Safety audit of a hydropower plant during refurbishment |
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196 | (3) |
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12.3.3 Application of SMORT in audits |
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199 | (2) |
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Chapter 13 Incident reporting and investigation |
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201 | (60) |
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13.1 Why investigate incidents? |
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201 | (1) |
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13.2 The steps in the investigation |
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202 | (2) |
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13.3 Investigations at three levels |
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204 | (5) |
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13.3.1 Applying SMORT in investigations at three levels |
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208 | (1) |
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13.4 Reporting and first recording of incidents |
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209 | (12) |
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13.4.1 Problems of underreporting |
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211 | (1) |
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13.4.2 The significance of reporting near accidents |
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212 | (3) |
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13.4.3 Behaviour theory applied to the reporting of incidents |
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215 | (2) |
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13.4.4 Employees' self-reporting of unwanted occurrences |
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217 | (3) |
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13.4.5 Reporting to the authorities |
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220 | (1) |
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13.5 Immediate (Level 1) investigation and follow-up |
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221 | (5) |
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13.5.1 The quality of the supervisor's first report |
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221 | (1) |
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13.5.2 Well-defined routines for reporting, investigation and follow-up |
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222 | (1) |
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13.5.3 Use of checklists and reporting forms |
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223 | (3) |
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13.6 Internal (Level 2) investigation |
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226 | (19) |
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13.6.1 Case: Incident involving flow of water into tunnel during repair work |
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226 | (1) |
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13.6.2 Establishing the sequence of events |
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227 | (6) |
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13.6.3 Identification and assessment of deviations |
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233 | (1) |
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233 | (2) |
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13.6.5 Analysis of contributing factors in the man-machine system and at the place of work |
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235 | (3) |
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13.6.5.1 Group problem-solving |
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236 | (2) |
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13.6.6 Investigating the human factor |
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238 | (3) |
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13.6.7 Developing accident prevention measures |
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241 | (1) |
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13.6.8 Quality assurance of the Level 2 investigation report |
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242 | (1) |
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13.6.9 Costs of accidents |
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243 | (1) |
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13.6.10 Computer-supported investigation, reporting and follow-up |
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243 | (2) |
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13.6.11 Procedure for Level 2 investigations |
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245 | (1) |
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13.7 Independent (Level 3) investigation |
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245 | (16) |
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13.7.1 The steps in an in-depth investigation. |
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248 | (7) |
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13.7.1.1 Securing the scene |
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249 | (1) |
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13.7.1.2 Appointing an investigation team |
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250 | (1) |
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13.7.1.3 Introductory meeting and planning the team's work |
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251 | (1) |
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13.7.1.4 Collection of information |
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252 | (1) |
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13.7.1.5 Evaluation and organising of information |
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253 | (1) |
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13.7.1.6 Preparing the team's report |
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254 | (1) |
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13.7.1.7 Follow-up meeting |
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255 | (1) |
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13.7.1.8 Follow-up and close-out |
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255 | (1) |
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13.7.2 Applying SMORT in Level 3 investigations |
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255 | (2) |
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13.7.2.1 Outline of a SMORT analysis |
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255 | (1) |
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13.7.2.2 Case: Incident involving flow of water into tunnel during repair work |
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256 | (1) |
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13.7.3 Legal aspects of the team's report |
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257 | (4) |
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Chapter 14 Accumulated incident experience |
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261 | (20) |
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14.1 Applying incident data in a safety information system |
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263 | (1) |
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264 | (2) |
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14.2.1 Coding of incident data |
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265 | (1) |
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14.3 Accessing the database |
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266 | (2) |
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14.4 Analysis of incident data |
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268 | (13) |
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14.4.1 Finding incident repeaters |
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268 | (1) |
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14.4.2 Uni- and bi-variate distribution analyses |
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269 | (2) |
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14.4.3 Incident concentration analysis |
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271 | (2) |
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14.4.4 Analysis of accident causes |
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273 | (2) |
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14.4.5 Analysis of remedial actions |
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275 | (1) |
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14.4.6 Statistical methods for incident analysis as part of continuous improvement |
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275 | (6) |
Section IV: Monitoring of safety performance |
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Chapter 15 Overview of safety performance indicators |
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281 | (8) |
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283 | (1) |
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15.2 Leading and lagging safety performance indicators |
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284 | (5) |
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Chapter 16 Loss-based safety performance indicators |
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289 | (16) |
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16.1 The lost-time and total recordable injury frequency rates |
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289 | (11) |
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290 | (4) |
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294 | (1) |
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16.1.3 Comparison among plants |
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295 | (1) |
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16.1.4 The problems of safety performance measurement |
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296 | (4) |
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300 | (1) |
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16.2 Other loss-based safety performance indicators |
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300 | (5) |
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Chapter 17 Process-based safety performance indicators |
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305 | (12) |
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305 | (3) |
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17.1.1 Employees' self-reporting of incidents and unwanted occurrences |
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306 | (1) |
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17.1.2 Reporting of incidents related to process safety |
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307 | (1) |
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17.1.3 Reporting of high-potential (HIPO) incidents |
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307 | (1) |
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17.1.4 Assessment relative to the quality criteria |
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308 | (1) |
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17.2 Reporting of deviations |
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308 | (9) |
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17.2.1 Statutory compliance |
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310 | (1) |
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17.2.2 Behavioural sampling |
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310 | (3) |
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17.2.3 Housekeeping index |
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313 | (1) |
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17.2.4 Barrier performance |
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314 | (1) |
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17.2.5 Assessment relative to the quality criteria |
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315 | (2) |
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Chapter 18 Causal factor-based safety performance indicators |
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317 | (16) |
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18.1 Performance indicators based on contributing factors at the workplace |
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317 | (3) |
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18.1.1 Measuring the degree of learning from incident investigations |
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317 | (2) |
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18.1.2 Assessment relative to quality criteria |
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319 | (1) |
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18.2 Performance indicators based on factors in corporate management and in the HSE management system |
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320 | (13) |
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18.2.1 General management factors |
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322 | (1) |
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18.2.2 HSE management system |
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323 | (6) |
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18.2.2.1 International Safety Rating System |
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324 | (2) |
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18.2.2.2 Self-rating as a means of improving HSE management |
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326 | (3) |
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18.2.3 Measurement of safety climate |
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329 | (1) |
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18.2.4 Assessment relative to the quality criteria |
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330 | (3) |
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Chapter 19 Selecting safety performance indicators |
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333 | (6) |
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19.1 Issues to be addressed in the selection process |
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333 | (1) |
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19.2 Examples of combinations of performance indicators |
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334 | (1) |
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334 | (1) |
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19.2.2 Plant or facility level |
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335 | (1) |
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19.3 Considerations regarding potential unwanted effects from the application of safety performance monitoring |
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335 | (4) |
Section V: Risk assessment |
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Chapter 20 The risk assessment process |
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339 | (14) |
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339 | (1) |
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20.2 The risk assessment process |
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340 | (6) |
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20.2.1 Establishing a risk picture |
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342 | (2) |
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344 | (2) |
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20.3 Methods of risk analysis |
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346 | (7) |
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Chapter 21 Coarse analysis |
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353 | (10) |
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354 | (2) |
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21.1.1 Objectives and decision requirements |
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354 | (1) |
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21.1.2 Describe and delimit analysis object |
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354 | (1) |
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21.1.3 Establish study team and analysis plan |
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355 | (1) |
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21.1.4 Background information and familiarisation |
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356 | (1) |
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21.2 Hazard identification and analysis of causes |
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356 | (1) |
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21.3 Establish the risk picture and evaluate the risk |
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356 | (3) |
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359 | (1) |
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21.4.1 Development of safety measures |
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359 | (1) |
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21.4.2 Documentation and follow-up of results |
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359 | (1) |
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21.5 Establishing a database on potential accidents |
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360 | (3) |
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Chapter 22 Job safety analysis |
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363 | (8) |
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22.1 Analysis object and organisation of the analysis |
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363 | (1) |
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364 | (3) |
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22.2.1 Description of the steps of the job |
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365 | (1) |
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365 | (2) |
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367 | (1) |
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22.3 Merits and limitations |
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367 | (1) |
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22.4 Systematic mapping of hazards within an organisation |
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368 | (3) |
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Chapter 23 Risk assessments of machinery |
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371 | (12) |
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23.1 Requirements as to risk assessments |
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371 | (1) |
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23.2 Method for risk assessment of machinery |
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372 | (11) |
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23.2.1 Determination of the limits of the machinery |
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374 | (2) |
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23.2.2 Hazard identification |
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376 | (1) |
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23.2.3 Risk estimation and evaluation |
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376 | (7) |
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Chapter 24 Comparison risk assessment |
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383 | (12) |
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24.1 Application of risk acceptance criteria in comparison analysis |
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383 | (1) |
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24.2 Risk-assessment model |
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384 | (3) |
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386 | (1) |
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24.3 The steps of the assessment |
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387 | (8) |
Section VI: Putting the pieces together |
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Chapter 25 The oil and gas industry |
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395 | (36) |
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25.1 Accidents in offshore oil and gas production |
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395 | (1) |
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396 | (1) |
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396 | (1) |
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25.2.2 Organisation and manning |
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397 | (1) |
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25.3 Prevention of accidents in design |
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397 | (19) |
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25.3.1 The phase model for the planning and execution of investment projects |
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397 | (3) |
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25.3.2 Safety management principles |
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400 | (7) |
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25.3.2.1 Acceptance criteria for the risk of losses due to accidents |
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402 | (1) |
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25.3.2.2 Experience transfer between operation and design |
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403 | (2) |
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25.3.2.3 Control and verification activities |
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405 | (2) |
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25.3.3 Prevention of major accidents |
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407 | (6) |
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25.3.3.1 Concept selection and definition |
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407 | (3) |
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25.3.3.2 Project execution |
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410 | (3) |
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25.3.4 Prevention of occupational accidents |
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413 | (3) |
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25.3.4.1 Concept definition and preparation for project execution |
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413 | (2) |
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25.3.4.2 Project execution |
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415 | (1) |
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25.4 Construction site safety |
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416 | (6) |
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416 | (1) |
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25.4.2 Step 2: Pre-qualification |
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417 | (1) |
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25.4.3 Step 3: Invitation to tender, evaluation and contract award |
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418 | (1) |
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25.4.4 Step 4: Mobilisation |
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419 | (1) |
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25.4.5 Step 5: Execution, follow-up during construction |
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419 | (3) |
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25.4.6 Step 6: De-mobilisation, evaluation and close-out |
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422 | (1) |
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25.5 Safety during plant operation |
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422 | (9) |
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25.5.1 HSE management principles |
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422 | (2) |
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424 | (1) |
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25.5.3 Planning and implementation |
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424 | (2) |
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25.5.4 Control and verification |
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426 | (5) |
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25.5.4.1 Reporting of accidents and unwanted occurrences |
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426 | (1) |
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25.5.4.2 Workplace inspections |
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427 | (1) |
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25.5.4.3 Control of barrier availability |
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427 | (2) |
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25.5.4.4 Risk assessments |
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429 | (1) |
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429 | (2) |
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Chapter 26 The hydropower industry |
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431 | (18) |
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26.1 Accident risks in hydropower development and operation |
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431 | (4) |
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26.1.1 Major accidents with multiple fatalities |
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432 | (2) |
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26.1.2 Occupational accidents |
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434 | (1) |
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26.2 The David hydropower plant |
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435 | (6) |
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26.2.1 The phase model for project management |
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437 | (1) |
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26.2.2 Management of accident risks in design |
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437 | (4) |
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26.3 HSE management in construction |
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441 | (6) |
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26.4 HSE management in operation and maintenance |
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447 | (2) |
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Chapter 27 Work-related road transportation |
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449 | (22) |
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27.1 Accidents in road transportation |
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449 | (1) |
|
27.2 Principles for the management of safety in road transportation |
|
|
450 | (10) |
|
|
450 | (1) |
|
27.2.2 Points for intervention |
|
|
451 | (7) |
|
|
452 | (2) |
|
|
454 | (2) |
|
27.2.2.3 The transportation environment |
|
|
456 | (2) |
|
27.2.3 Road transportation safety management |
|
|
458 | (2) |
|
27.3 Case: Road safety management practices in a power company |
|
|
460 | (11) |
|
27.3.1 Road transportation safety management |
|
|
461 | (2) |
|
27.3.2 Road transportation risk assessment |
|
|
463 | (8) |
|
|
471 | (4) |
Appendix A: Definitions |
|
475 | (4) |
Appendix B: SMORT checklists and questionnaire |
|
479 | (36) |
Bibliography |
|
515 | (18) |
Index |
|
533 | |