Guidance
CAST Handbook: How to Learn More from Incidents and Accidents
CAST Handbook: How to Learn More from Incidents and Accidents
- Open access
- Guidance
- Unknown
- Human FactorsIncident InvestigationLearning from Incidents
- Human factorsIncident investigationLeadership and safety cultureLearning from incidentsSystems-theory safety
- Management of changeOperating and work proceduresRisk assessmentSafety communication
Summary
This handbook teaches CAST, a systems-theory method for analysing accidents without assigning blame. It explains control-structure modelling, controller responsibilities, feedback, human decision contexts and systemic weaknesses. Chemical-plant, workplace and social-system cases illustrate the method, alongside guidance on recommendations, organisational adoption and checking whether improvements are effective.
Classifications: Human factors; human performance; ergonomics.
Classifications: Incident investigation; accident investigation.
Classifications: Leadership and safety culture; safety culture; safety leadership.
Classifications: Learning from incidents; incident learning; lessons learnt; lessons learned.
Classifications: Systems-theory safety.
Classifications: Management of change; MOC; change management.
Classifications: Operating and work procedures.
Classifications: Risk assessment; hazard assessment.
Classifications: Safety communication; toolbox talk; toolbox talks.
Summary
Nancy Leveson's handbook describing CAST, a systems-theory approach to analysing accidents and incidents that looks beyond blame to weak control structures.
Themes: human factors, incident investigation, learning from incidents.