Hierarchy of controls in Contra Costa Health Services (<scp>CCHS</scp>) incident investigations
Why this work is in the frame
A frame that forgets how it found something cannot be audited. These are the routes that admitted this work.
Bibliographic record
Abstract
Abstract Industrial safety ordinance (ISO), implemented in Contra Costa County in 1998, and in the city of Richmond in 2000, expands on the California accidental release program (CalARP) and requires the consideration of inherently safer design (ISD). Identifying ISD‐based corrective actions as part of incident investigations is an opportunity to consider ISD within the existing process safety management framework. The objectives of this work were to analyze corrective actions from ISO incident investigation reports with respect to the hierarchy of controls, to identify additional ISD‐based corrective actions for an incident using the ISD bow tie protocol, and to develop additional ISD example‐based guidance. Thirty incidents from 2001 to 2018 were analyzed, and 227 recommended corrective actions were documented and categorized according to the hierarchy of controls. An incident at the Tesoro Golden Eagle Refinery on September 15, 2004 was analyzed, and five additional ISD‐based corrective actions were identified. This work suggests that using the ISD bow tie protocol and example‐based guidance, in addition to ISD checklists and guidewords in incident investigations could help identify more ISD‐based corrective actions.
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Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.004 | 0.002 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.000 |
| Bibliometrics | 0.001 | 0.004 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.001 |
| Open science | 0.001 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.000 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from it