Professional Documents
Culture Documents
TripodBeta 01
TripodBeta 01
and
Event
Target
HAZARD, EVENT AND TARGET
In this incident:
Operative falls in
shower room
Operative
IS THE INVESTIGATION COMPLETE?
Failed
Barrier Operative falls in
shower room
Operative
INCIDENT MECHANISM
Wet floor
(slipping hazard)
Operative falls in
shower room
Operative
Wet floor
(slipping hazard)
Floor
drying Operative falls in
shower room
Operative
END OF INVESTIGATION?
Restriction on Cleaner
Congestion
Latent
private
Failure Pre-condition Unable to keep
1800-1900 hrs.
phone calls floor dry
Lat. Failure Pre-condition Active failure
Wet floor
(slipping hazard)
Floor
drying Operative falls in
shower room
Operative
TRIPOD THEORY OF ACCIDENT
MANAGEMENT
Fallible
Latent Active
Management Pre-condition
Failure Failure
Decision
Lat. Failure Pre-condition Active failure
Failed
Barrier
RECOMMENDATIONS