1. 1 www.bst-tsb.gc.ca

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8. 8 Human insight ISIM – The Big Picture A TSB tool to derive safety knowledge from accident data Context Information Data Findings Safety Deficiencies Recommendations Inv. Reports Knowledge ISIM Observations Witness Statements Instrument Recordings Tests Injury Debris / Wreckage Decisions Records & Documents Human elements Org. Elements Competency, Training

9. 9 Event - 1 Time or est. time Data source Actor Action (Descriptors) Event Location Event - 2 Event 3 Event 4Event 5 Pre-Occurrence Events Post-Occurrence Events Sequence of Events - Convention Accident

10. 10 Event - 1 Event - 2 (Safety Significant) Event 3Event 4Event 5 Pre-Occurrence Events Post-Occurrence Events Occurrence Sequence of Events Unsafe Act Why Unsafe Condition Because Why Underlying Factor Because Accident

11. 11 Defence (Barrier) Analysis Management Decisions Org. Processes Corporate Cultures, etc. Errors Violations Error- Producing Conditions Violation- Producing Conditions Defence Organisation PersonWorkplaceDefences

12. 12 Qualitative Risk Assessment FrequentProbableOccasionalUnlikelyMost Improbable Catastrophic High Medium Low Major High Medium Low Moderate HighMedium Low Negligible Low

13. 13 Engineer & Design for minimum hazards Guard, Protect and Defend Policy & Procedures Train & Educate Warn Rehabilitate Safety Precedence Sequence as Risk Control Strategy Risk Control Options Safety Precedence Sequence MOST Least

14. 14 www.bst-tsb.gc.ca