Most industries have begun to consider the feasibility of collecting and analyzing information about precursors before they result in mishaps. Too often, the “hands-on” people on the “front lines” note, after a mishap, that, they “all knew about that problem.” The challenge is to collect the information “we all know about” and do something about it before it results in a mishap.

Many industries have instituted mandatory reporting systems to collect information. They generally find, however, that there is no reasonable way to mandate the reporting of occurrences that do not rise to the level of mishaps or potential regulatory violations. Short of a mishap, the system must generally rely upon voluntary reporting, mostly from frontline workers, for information about problems. In the aviation industry, reporting about events near the top of the pyramid is generally mandatory, but reporting most events in the large part of the pyramid is generally voluntary. In most industries, including aviation, most of the information necessary for identifying precursors and addressing them is likely to be in the large part of the pyramid.

In the United States, four factors have discouraged frontline workers, whose voluntary reporting is most important, from coming forth with information. First, potential information providers may be concerned that company management and/or regulatory authorities will use the information for punitive or enforcement purposes. Thus, a worker might be reluctant to report a confusing process, fearing that management or the government might not agree that the process is

Front Matter (R1-R12)

Section I Committee Summary Report1 The Accident Precursors Project: Overview and Recommendations (1-34)

Section II Keynote Speakers2 The Opportunity of Precursors (35-44)

On Signals, Response, and Risk Mitigation: A Probabilistic Approach to the Detection and Analysis of Precursors (45-60)

Section III Risk Assessment4 Understanding Accident Precursors (61-78)

5 Defining and Analyzing Precursors (79-88)

6 Nuclear Accident Precursor Assessment: The Accident Sequence Precursor Program (89-100)

Section IV Risk Management7 Inherently Safer Design (101-118)

8 Checking for Biases in Incident Reporting (119-126)

9 Knowledge Management in High-Hazard Industries: Accident Precursors as Practice (127-136)

Section V Linking Risk Assessment and Risk Management10 Cross-Industry Applications of a Confidential Reporting Model (137-146)

11 Stuck on a Plateau: A Common Problem (147-154)

12 Ensuring Robust Military Operations and Combating Terrorism Using Accident Precursor Concepts (155-174)

Appendix A Letters to the Committee (175-186)

Appendix B Workshop Agenda (187-190)

Appendix C Workshop Participants (191-196)

Appendix D A Note on Definitions (197-198)

Appendix E Biographies of Authors (199-204)

Appendix F Biographies of Committee Members (205-208)