Search

Introduction: We aimed to identify the possible chain of events leading to fatal scuba diving incidents in Australia from 2001–2013 to inform appropriate countermeasures. Methods: The National Coronial Information System was searched to identify scuba diving-related deaths from 2001–2013, inclusive. Coronial findings, witness and police reports, medical histories and autopsies, toxicology and equipment reports were scrutinised. These were analysed for predisposing factors, triggers, disabling agents, disabling injuries and causes of death using a validated template. Results: There were 126 known scuba diving fatalities and 189 predisposing factors were identified, the major being health conditions (59; 47%), organisational/training/experience/skills issues (46; 37%), planning shortcomings (29; 23%) and equipment inadequacies (24; 19%). The 138 suspected triggers included environmental (68; 54%), exertion (23; 18%) and gas supply problems (15; 12%) among others. The 121 identified disabling agents included medical-related (48; 38%), ascent-related (21; 17%), poor buoyancy control (18; 14%), gas supply (17; 13%), environmental (13; 10%) and equipment (4; 3%). The main disabling injuries were asphyxia (37%), cardiac (25%) and cerebral arterial gas embolism/pulmonary barotrauma (15%). Conclusions: Chronic medical conditions, predominantly cardiac-related, are a major contributor to diving incidents. Divers with such conditions and/or older divers should undergo thorough fitness-to-dive assessments. Appropriate local knowledge, planning and monitoring are important to minimise the potential for incidents triggered by adverse environmental conditions, most of which involve inexperienced divers. Chain of events analysis should increase understanding of diving incidents and has the potential to reduce morbidity and mortality in divers.

In chain of events model, an accident path is defined by a series of sequential events from initiating event to accident realization. In this study, we define accident path as a 5-tuple set comprising hazardous element (HE), initiating event (IE), pivotal event (PV), accident scenario (AS), and consequence (C). We propose a new methodology to identify the path components (i.e., HE, IE, PV, AS and C) and quantify the path using data analytics approach. We have used both proactive (workplace observation (WO) and high risk control program (HRCP)) and reactive data (incident records (IR)) for this quantification. The HEs and their corresponding IEs are extracted from WO and HRCP, and then, IR is used to identify PVs, ASs and Cs. In the process, we have used K-modes categorical clustering and Expectation-Maximization (EM) algorithm based text clustering. We could identify 39 accident paths using proposed approach and after quantification, nine paths are found to be frequently recurring. Preventive strategies are identified for accident paths of high concern. The quantification of accident paths will assist safety management in decision making by prioritizing accident paths and assessing performance of preventive barriers. By the use of data mining techniques, experts will not have to read the huge safety data for accident path analysis. This analysis can be done by experts by identifying safety keywords from the clusters generated by clustering algorithms. This will reduce the labour of safety experts in accident analysis with respect to time and resource.

Objective: The objective of this article is to describe the characteristics of fatal crashes with bicyclists on Swedish roads in rural and urban areas and to investigate the potential of bicycle helmets and different vehicle and road infrastructure interventions to prevent them. The study has a comprehensive approach to provide road authorities and vehicle manufacturers with recommendations for future priorities. Methods: The Swedish Transport Administration’s (STA) in-depth database of fatal crashes was used for case-by-case analysis of fatal cycling accidents (2006–2016) on rural (n = 82) and urban (n = 102) roads. The database consists of information from the police, medical journals, autopsy reports, accident analyses performed by STA, and witness statements. The potential of helmet use and various vehicle and road infrastructure safety interventions was determined retrospectively for each case by analyzing the chain of events leading to the fatality. The potential of vehicle safety countermeasures was analyzed based on prognoses on their implementation rates in the Swedish vehicle fleet. Results: The most common accident scenario on rural roads was that the bicyclist was struck while cycling along the side of the road. On urban roads, the majority of accidents occurred in intersections. Most accidents involved a passenger car, but heavy trucks were also common, especially in urban areas. Most accidents occurred in daylight conditions (73%). Almost half (46%) of nonhelmeted bicyclists would have survived with a helmet. It was assessed that nearly 60% of the fatal accidents could be addressed by advanced vehicle safety technologies, especially autonomous emergency braking with the ability to detect bicyclists. With regard to interventions in the road infrastructure, separated paths for bicyclists and bicycle crossings with speed calming measures were found to have the greatest safety potential. Results indicated that 91% of fatally injured bicyclists could potentially be saved with known techniques. However, it will take a long time for such technologies to be widespread. Conclusions: The majority of fatally injured bicyclists studied could potentially be saved with known techniques. A speedy implementation of important vehicle safety systems is recommended. A fast introduction of effective interventions in the road infrastructure is also necessary, preferably with a plan for prioritization.

Introduction: This study reviews diving deaths that occurred in Tasmanian waters over a 20-year period. Methods: Detailed analysis was undertaken of deaths that occurred from 01 January 1995 to 31 December 2014. The cases were collated from numerous sources. Utilising a chain of events analysis, factors were identified and assigned to predisposing factors, triggers, disabling agents, disabling injuries and cause of death. These were then scrutinised to ascertain regional variables, remediable factors and linkages which may benefit from targeted risk mitigation strategies. Results: Seventeen deaths were identified across this 20-year period, which included one additional case not previously recorded. All were recreational divers and 15 were male. Five were hookah divers, 12 were scuba divers. Important predisposing factors identified included equipment (condition and maintenance), pre-existing health conditions, diver experience and training. These factors can now be used to promote public health messages for divers. Conclusions: This 20-year study highlighted regional variations for Tasmanian deaths and presents opportunities for strategies to prevent diving deaths in the future. Of particular concern was the diving practice of 'hookah' diving, which has no governing regulations. The study highlighted the importance of applying a structured methodology such as chain of events analysis to scrutinise diving deaths.

Introduction Problems concerning occupational safety and health are commonly found in the construction industry, including falling materials, tools or people from a height, stepping on objects, and injuries caused by hand tools. An important factor in occupational safety in the construction industry is the use of scaffolds. All scaffolds used in construction, renovation, repair (including isolating, painting and decorating) and demolition, should be erected, maintained and dismantledin accordance with safety procedures. Therefore, it is crucial to deal with the safety of scaffolds and risk assessment in the construction industry; thus, the way of undertaking the assessment and the liability of assessment seems to be essential for professionals. However, it has been found that those professionals are prone to rely heavily on their own experience and knowledge in decision-making regarding risk assessment. Material and methods The Scaffold Use Risk Assessment Model (SURAM) has been developed for assessing risk levels at various stages of the construction process in various work trades. The SURAM is the result of a research project carried out at 60 construction sites in Poland and Portugal where 504 observations have been completed including both harmful physical and chemical factors, stress level, workers' habits, as well as a hundreds ex-post reconstruction of construction accidents scenarios. Results It was found that the workers' Health Behaviour Index (HBI) seems to be a more direct predictor for development of the unsafe chain of events leading to an accident than the workload, and concentration of harmful factors at the workplace. Conclusions The developed HBI module of SURAM seems to be beneficial for predicting high-risk construction activities, and thus preventing the occurrence of accidents, based on a set of historical accident data.

BACKGROUND An adverse event is defined as any unintentional harm that results in temporary or permanent disability and/or prolongation of hospitalization time, or death of a patient; as a consequence of health care provided by any staff member of the health institution. OBJECTIVES The aim was to describe the adverse events that affect patient safety, reported in 2015 in a private hospital in the city of Cordoba, Argentina. METHODS We analyzed 678 events reported through the computer system on the hospital's intranet. RESULTS The highest frequency of events reported corresponded to the nursing professionals (40.7% ). Problems related to drug therapy process showed the highest frequency of reports (17.7% ), followed by communication failures (11.1% ) and patient's fall (10.3% ). In the notification of the causes of the incident, 51.9% of "No answer" was observed. CONCLUSION In the case of this hospital, this valuable tool is being underutilized. The reports should allow identifying the entire chain of events that lead to the incidents to address effective interventions in patient safety that involve all hospital staff, with greater emphasis on senior staff.

The operating environment of merchant ships is dynamic and complex. Particularly, their engine rooms and bridges have complex structures that contain various equipment. In addition, there is the human factor that manages all this complex structure. The systems on-board ships involve interactions between crew, hardware, and software (man-machine interfaces). As a consequence of the growing complexity of socio-technical systems, traditional accident analysis methods are getting inadequate to analyse the complex systems. The conventional analyses are focused on the chain of events and they have limited ability to overcome non-linear interactions among dynamic and complex system components in maritime transportation. The aim of this paper is to apply a Systems Theoretic Accident Model and Process (STAMP) model for the analysis of a ship allision accident occurring in narrow waters. This is to create a wider view of the accidents rather than a simple chain of events. With the help of detailed STAMP analysis, the dynamic nature of the system, errors in the entire structure, including the human, machine, and software interactions can be analysed. The model also identifies violations of safety constraints at all levels of the control structure, even though the accident involved a complex and dynamic process. The results demonstrate that complex system accidents are not a simple cause-effect chain of events, on the contrary, they are system-based, dynamic, and complex situations. Consequently, the paper tried to reveal all the causes of the Vitaspirit Allison, rather than just one component.

On March 8, 2014, a Malaysia Airlines Boeing 777 carrying flight MH-370 from Kuala Lumpur to Beijing disappeared during its flight. In this paper, we employ a model-based approach to capture and study the chain of events leading to the disappearance of the aircraft. We show that the critical reason for the aircraft’s disappearance was a cyber-physical gap (CPG). The CPG is the difference between the real state of a physical entity and its state as perceived by cybernetic agents. Failure to acknowledge the CPG’s existence, capture it in system models, and incorporate suitable mitigation mechanisms into systems exposed to CPG, has resulted in the past and may result in the future in severe consequences. In the MH-370 case, the plane’s position and adherence to its flight course were misperceived by the air traffic control, resulting in failure to track and find the plane, to this day. Our approach to CPG analysis has been previously shown to assist both designers and users handle emergent situations resulting from CPGs, such as the Three-Mile Island nuclear reactor’s partial meltdown accident in 1979. We propose several mitigation mechanisms, whose integration with air traffic control systems could help prevent similar cases in the future.

Introduction A scuba diving fatality usually involves a series of related events culminating in death. Several studies have utilised a chain of events-type analysis (CEA) to isolate and better understand the accident sequence in order to facilitate the creation of relevant countermeasures. The aim of this research was to further develop and better define a process for performing a CEA to reduce potential subjectivity and increase consistency between analysts. Methodology To develop more comprehensive and better-defined criteria, existing criteria were modified and a template was created and tested using a CEA. Modifications comprised addition of a category for pre-disposing factors, expansion of criteria for the triggers and disabling agents present during the incident, and more specific inclusion criteria to better encompass a dataset of 56 fatalities. Four investigators (raters) used both the previous criteria and this template, in randomly assigned order, to examine a sample of 13 scuba diver deaths. Individual results were scored against the group consensus for the CEA. Raters' agreement consistency was compared using the Index of Concordance and intra-class correlation coefficients (ICC). Results The template is presented. The index of concordance between the raters increased from 62% (194⁄312) using the previous criteria to 82% (257⁄312) with use of this template indicating a substantially higher inter-rater agreement when allocating criteria. The agreement in scoring with and without template use was also quantified by ICC which were generally graded as low, illustrating a substantial change in consistency of scoring before and after template use. Conclusion The template for a CEA for a scuba diving fatality improves consistency of interpretation between users and may improve comparability of diving fatality reports.

A network of serial, parallel and cross-related factors transfers the hazard energy until the accident occurs. This paper aims to discuss the failure of barriers initially built to prevent the accident, the factors that need to be included in the analysis to review human elements and their safeguards, and the need for critical judgment for resilient and accident-alert safe behavior. It is intended to study past accidents and establish relationships between these factors, antecedents and consequences. The availability of a competent team to interpret the chain of events that can lead to the accident is crucial in ending the hazardous energy migration. It is expected to measure the ability to increase or decrease the hazardous energy considering ship collision with oil leak. Analysis of human elements in the project before and after the accident layer factors may suggest changes in safeguards or recommendation of new barriers to the accident.

Background Diagnostic error occurs more frequently in the emergency department than in regular in-patient hospital care. We sought to characterise the nature of reported diagnostic error in hospital emergency departments in England and Wales from 2013 to 2015 and to identify the priority areas for intervention to reduce their occurrence. Methods A cross-sectional mixed-methods design using an exploratory descriptive analysis and thematic analysis of patient safety incident reports. Primary data were extracted from a national database of patient safety incidents. Reports were filtered for emergency department settings, diagnostic error (as classified by the reporter), from 2013 to 2015. These were analysed for the chain of events, contributory factors and harm outcomes. Results There were 2288 cases of confirmed diagnostic error: 1973 (86%) delayed and 315 (14%) wrong diagnoses. One in seven incidents were reported to have severe harm or death. Fractures were the most common condition (44%), with cervical-spine and neck of femur the most frequent types. Other common conditions included myocardial infarctions (7%) and intracranial bleeds (6%). Incidents involving both delayed and wrong diagnoses were associated with insufficient assessment, misinterpretation of diagnostic investigations and failure to order investigations. Contributory factors were predominantly human factors, including staff mistakes, healthcare professionals’ inadequate skillset or knowledge and not following protocols. Conclusions Systems modifications are needed that provide clinicians with better support in performing patient assessment and investigation interpretation. Interventions to reduce diagnostic error need to be evaluated in the emergency department setting, and could include standardised checklists, structured reporting and technological investigation improvements.

Introduction The aim of this study was to identify characteristics of victims of fatal snorkelling and breath-hold diving accidents in Australia from 2001-2013, inclusive, to determine underlying factors and risks associated with such activities and inform appropriate countermeasures. Methods The National Coronial Information System (NCIS) was searched to identify snorkelling and breath-hold diving-related cases reported to Australian coroners for the years 2001-2013, inclusive. Coronial data in the form of findings, witness and police reports, medical histories and autopsies were collected and collated, and descriptive statistics were used to analyse these data. A chain of events analysis was used to determine the likely sequence of events. Results There were 175 identified snorkelling-related fatalities during the study period. Most victims were middle-aged males (mean age 49 years). Pre-existing health conditions were possible contributors to 41% of the deaths, the main being ischaemic heart disease. The majority of deaths occurred in Queensland in inexperienced snorkellers, often in commercial settings. The victim's plight often went unnoticed as they were alone, or poorly supervised, when the incident occurred. Apnoeic hypoxia appeared to have been associated with at least 12.5% of the deaths. The main disabling injuries were asphyxia (40%) and cardiac incidents (35%). Conclusion Human factors, such as chronic health conditions, poor skills and inexperience and poor planning can play a substantial role throughout the chain of events leading to a snorkelling fatality. It is important to educate the community, doctors and dive industry professionals about potential problems associated with the interaction between certain health-related conditions, especially cardiovascular conditions, and snorkelling. Close supervision is strongly recommended for inexperienced snorkellers due to their likely poor skills, as well as for experienced breath-hold divers due to the potential for apnoeic hypoxia.

Security threats on the industrial automated control systems (IACSs) are becoming a growing concern for all the industrial facilities, and in particular for those where large quantities of hazardous substances are stored or handled (e.g. Seveso sites in Europe). Remote (cyber) or physical malicious manipulations of the automated control system of Seveso sites may have consequences comparable to those of conventional major accidents due to internal causes (e.g. loss of containment of hazardous materials, fires, explosions). While consolidated approaches exist to manage and control the cybersecurity of IT and OT systems of a facility, there is an evident lack of procedures to assess the actual link between malicious manipulations of the safety and control systems and the major accidents that can be triggered. In the present study, a specific methodology (PHAROS) was developed to address the identification of major accident scenarios achievable by malicious manipulation of physical components of the plant through the control and safety instrumented systems. The methodology, which exploits a reverse-HazOp concept, also analyses the role of the existing safety barriers in contrasting the chain of events triggered by the malicious manipulation, and may support the definition of design specifications and/or possible IT protection requirements for such barriers. The methodology was applied to a demonstrative case study to understand the features of the results obtained and their potential towards the improvement of the security of the process facility.

Background: A good quality report should lend itself for detailed analysis of the chain of events that lead to the incident. This knowledge can then be used to consider what interventions, and at what level in the chain, can prevent the incident from occurring again. Aim was to study the occurrence of adverse events on the basis of incident reporting. Methods: Critical analysis of incident reporting of adverse events taking place in admitted patients for one year by using WHO Structured questionnaire on patient safety (RF-1 & RF-2 forms) along with their record review and interview to the concerned staff. Results: 253 incidents of adverse events were reported during the study period of one year. Most common screening criteria being, Patient/family dissatisfaction with care received, documented or expressed during the current (221 incidents i.e. 87.35%), followed by hospital acquired infection/sepsis (29 incidents i.e. 11.46%). 13 incidents (5.13%) were reported for unexpected deaths due to adverse events. 38.9% of reported adverse events studied showed signs of health care team responsible for causing adverse events. 39% of adverse events were found preventable and 61% of adverse event was found non-preventable. Conclusions: Incident reporting of adverse events should be encouraged in all hospitals.

Objectives: We aimed at testing a model of the direct and indirect effects of being a part-time 28 farmer on the probability of being involved in an agricultural machinery-related accident, 29 considering the role played by unsafe beliefs and the frequency of use of machinery. 30 Methods: Two-hundred and fifty-two Italian men, regular users of agricultural machinery 31 (age: Mean = 45.1 years, standard Deviation = 17.5), were administered a paper-and-pencil 32 questionnaire addressing their relation with work, unsafe beliefs, and previous experience of 33 machinery-related accidents. 34 Results: Being a part-time farmer showed a positive association with unsafe beliefs only 35 among occasional machinery users. Unsafe beliefs in turn showed a positive association with 36 accidents. 37 Conclusions: The study gave a novel contribution to the knowledge of the chain of events 38 connecting part-time farmers with machinery-related accidents. Preventive training 39 interventions targeting part-timer farmers using agricultural machinery just occasionally 40 should be developed.

Objective: We investigated the risk factors for falls when egressing from agricultural tractors, analyzing the role played by worked hours, work experience, operators' behavior, and near misses. Background: Many accidents occur within the agricultural sector each year. Among them, falls while dismounting the tractor represent a major source of injuries. Previous studies pointed out frequent hazardous movements and incorrect behaviors adopted by operators to exit the tractor cab. However, less is known about the determinants of such behaviors. In addition, near misses are known to be important predictors of accidents, but they have been under-investigated in the agricultural sector in general and as concerns falls in particular. Method: A questionnaire assessing dismounting behaviors, previous accidents and near misses, and participants' relation with work was administered to a sample of Italian tractor operators (n = 286). Results: A mediated model showed that worked hours increase unsafe behaviors, whereas work experience decreases them. Unsafe behaviors in turn show a positive association with accidents, via the mediation of near misses. Conclusions: We gave a novel contribution to the knowledge of the chain of events leading to fall accidents in the agricultural sector, which is one of the most hazardous industries. Applications: Besides tractor design improvements, preventive training interventions may focus on the redesign of the actual working strategies and the adoption of engaging training methods in the use of machinery to optimize the learning of safety practices and safe behaviors

Billions of ringgits are consistently being invested by the oil and gas companies to ensure pipeline integrity, especially to address problems caused by pipelines. However, the existing solutions in predicting corrosion occurrence often lead to an extremely high cost to be implemented. Worse, the current implementations require manual data entry, which lengthen the time taken for processing in order to obtain a reliable corrosion prediction. If a corroded pipeline failed to be predicted much earlier, the pipes might burst and will cause a significant chain of events that will affect the aqua eco-system. The companies will suffer huge financial losses to mitigate the catastrophic situation. Hence, a better pipeline corrosion determination mechanism needs to be developed to address the issues found in this dissertation. Through early prediction on the corrosion occurence, it will provide the user with the knowledge for a better decision making. This paper will deliberate on a system that predicts corrosion rate using the deWaard- Milliams model. Arduino UNO R3 was used in this project, in predicting the corrosion rate. As a proof of concept and performance, simulations were carried out using synthetic dataset to test the efficiency of the proposed system. Synthetic data was generated through the Gaussian function in Java. The proposed prototype was tested. Three types of testing were conducted which are data quality test, accuracy test and corrosion rate analysis. Data quality test is to ensure the synthetic data generated are closely matched with real data. Accuracy test evaluates the predicted corrosion rate against the real field data obtained from literature studies. Corrosion rate analysis provides an overview and comparison between the effects of the parameters determining the corrosion rate and the predicted corrosion rate. The results exhibit the capability of the mechanism to accurately predict the corrosion rate.

In many major cities, bicycle usage is on the increase and cycling safety is becoming a critical issue. Most of the existing studies are based on police data which understate both single-bicycle accidents as well as cyclist victims. In France, an estimation based on a road trauma database reveals that cyclists are 8 times more likely to be injured per hour spent on the road compared to motorists. To give a full picture of cycling accidents, as well as to understand how cyclist behavior interacts with other factors in causing accidents, we sur-veyed all injured cyclists in the period 2009-2011, as identified in a medical database of road trauma victims in a French territorial 'départment' (the Rhône, capital city Lyon). Using classification methods we build a typology of 17 recurring configurations of cycling collisions and single-bicycle accidents: 7 concern utilitarian riding (commuting ...), 3 concern recreational riding and 7 concern cycling as a sporting activity. A Multiple Correspondence Analysis (MCA) is then used to check the consistency of this typology, and to gain additional insight on road user behavior by projection of supplementary variables. External factors contributing to cycling accidents, such as 'bad weather' (13%) or 'riding at night' (14%), roadway configuration such as 'cycling infrastructure' (16%) or 'intersections' (25%), and cyclist behavior such as 'alcohol consumption' (5%) or 'speed' (25%) are discriminatory variables that interact in many accident configurations. This study shows how road user behavior-influences each step in the chain of events leading to an accident. In the discussion of study results, some recommendations are made to public authorities aimed at improving cyclist safety.; Dans de nombreuses villes de taille importante, l'usage du Îlo est en augmentation. le sécurité en Îlo devient donc une priorité. La plupart des études existant sur le sujet sont basées sur les données policières qui sous-estiment les accidents de Îlo survenus seuls, de même que le nombre de victimes d'accidents coroprels chez les usagers de Îlo. En France l'estimatioon de ce nombre de victimes à partir d'un Registre detraumatisés de la route donne des chiifres 8 fois plus éleÎs que les données policières pour donner une image plus complète des accidents à Îlo, et pour mieux comprendre comment les habitudes de conduite des cyclistes interagissent avec d'autres facteurs ds la survenue des accidents, nous avons envoyés un questionnaire à toutes les victimes d'accidents de Îlo enregistrées dans le Registre du Rhône sur la période 2009-2011. Nous avons construit une typologie de 17 configurations d'accidents cyclistes : 7 regroupent les accidents survenus sur un ttrajet utilitaire, 3 concernent les accidents lirs de sorties récréationnelles, et 7 concernent les accidents survenus lors d'une activité sportive. A côté des facteurs extérieurs comme le mauvais temps (13%) ou la conduite nocturne (14%), les configurations des infrastructures cyclistes (16%) ou les intersections (25%), les facteurs comportementaux comme la consommation préalable d'alcool (5%) ou la vitesse (25%) sont des variables qui interviennent ds de nombreuses configurations d'accidents cyclistes.