Incidents occur when required operating states (ROS) are compromised by credible failure modes because the business inputs that should prevent or mitigate the compromised are:
- inadequate (poor design and/or poor specification
- Inadequately implemented (people do not understand business input requirements)
- Not being applied (monitoring of business input status is inadequate)
Credible Failure mode is addressed by:
- BI.00.23 Incident Reporting, Investigation and assigning Corrective Actions that improve business processes.
- BI.01.05 Response to alarms and other vehicle notifications – information prepared for operators
CFM00.33 – Failure to learn from near miss incidents i.e. compromised required operating states for tyre management
Last Updated: 23/01/2023 03:16:58pm