Skip to main content

Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities (2002) / Chapter Skim
Currently Skimming:

Appendix F: Causal Tree Analysis of December 3-5, 2000, Event at JACADS
Pages 103-105

The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.


From page 103...
... These same actions may have resulted in safe outcomes on previous occasions, but 103 in the incidents examined by the committee, such actions combined with latent failures to cause some adverse consequences. Examples of active failures include use of the wrong procedure, incorrect performance of an appropriate procedure, or failure to correctly and rapidly diagnose a problem.
Read the entire page →
From page 104...
... 104 tn o tn aa tY aa tn , ~1~11 LL = ~ ^ U
Read the entire page →
From page 105...
... 703 1 I ~ 1 c o o ~ ~ ~ < Baa a< O = 0 < .E bi ~: ~ o ~ ~ ..
Read the entire page →

Key Terms

  • incidents examined
  • adverse consequences
  • active failures
  • include equipment
  • appropriate procedure

  • standard operating
  • normal activities
  • charts supplied
  • rapidly diagnose
  • routine ignoring

  • personnel decisions
  • equipment design
  • failures include
  • army indicate
  • actions combined

  • analysis suggests
  • examples include
  • outcomes naturally
  • flow charts
  • design deficiencies

  • naturally receive
  • safe outcomes
  • unexpected configurations
  • committee grew
  • latent failures

  • local community
  • subsequent responses
  • investigation flow
  • previous occasions
  • dangerous events


    • This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
    More information on Chapter Skim is available.