To prevent human error a range of techniques are available, some more effective than others. Accidents are more likely caused by a systematic migration toward accidents by an organization operating in an aggressive, competitive environment. 4 According to Rasmussen 5 accidents are the result of lack of control: ‘A closer look at major accidents indicates that the observed coincidence of multiple errors cannot be explained by a stochastic coincidence of independent events.
2,3 Safety does not, as many experts believe, depend on the number of sprinklers and hydrants installed, but a high proportion of accidents and catastrophes are the obvious result of management error. The common factor in this trend is the theory that prevention of human error is most effectively gained by controlling the working environment instead of focusing at the individual who ‘failed’. Since the publication of Human Error in 1990 1 a consistent trend in the interest in the contribution of human error to industrial accidents can be noticed. Results show that using TRACK increases the consistency and objectivity of the investigation, and forces the investigator to dig deeper than with any other tool available. TRACK facilitates the process of fact-finding and enables the investigator to get away from the "what happened" to the "what made it happen". This paper describes a new tool in the Tripod family: TRACK. The method itself however is not explicitly designed for fact-finding, although the Tripod Framework does give a clear direction and supports finding facts. Tripod Beta is seen as a state-of-the-art method to analyse incidents. By identifying and remedying these systemic causes, entire classes of incidents can be prevented.īased on the Tripod theory, Tripod Beta has been developed as an instrument to analyse incidents. The better the investigation and analysis, the more one finds the systemic causes of incidents. The quality of the investigation and analysis determines on what level remedial actions can take place. Incident investigation and analysis is an essential part in identification of risks and managing the business process.
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