Chapter 4 - Accident Investigation

complex accidents

- multiple employees - equipment - procedures - tasks

non-complex accidents

- one employee - one tool

Accident sequence; systematic; exhaustive approach

An accident investigator must use a structured process to develop the _______ ________ and a _________ and _________ _________ to analyze evidence and determine casual factors

1. First cause 2. Last cause 3. Cause of prevention 4. Cause from management 5. Cause that started the accident sequence 6. Cause that would have prevented the accident if it had not happened

Root cause - six steps

Training in analytical techniques

What helps investigators to determine how much they need to find out about an accident and how much interviewing and data collection are necessary

Analysis

What is a systematic and exhaustive process used ro determine what is unknown about an accident by examining all of the known facts or circumstances surrounding it

dial-a-cause

this is known as a list of possible roots causes and designates one of them as the root cause of each accident. It also allows safety professionals to make excellent charts and graphs for studying trends

root cause analysis

More of a process than an investigative tool or analytical tool

Structured thinking

A process that does not come naturally to everyone

1. Investigate phase 2. Analytical phase 3. Recommendation phase

Accident investigations are conducted in what three phases

Gain knowledge

Discover facts about the accident, interview witnesses, obtain documentation

Systematic process

Enables the investigator to determine corrective actions that will not only prevent recurrence of the accident

Analytical approach

Establishes consistency and lends validity to the accident Investigation process

Casual factors

Events in the accident sequence that are deemed to have been causes or significant factors

Develop corrective actions

How can similar accidents be prevented

All levels

Investigators must analyze events at ________ ________ to determine the causes of the accident as well as recommended corrective actions

Corrective actions

It is difficult to determine _________ __________ if the accident sequence and casual factors have not been identified

Analytical phase of accident investigation

Starts with discovering facts about the accident and using them to determine the accident sequence deriving the casual factors

Problem solving process

The accident investigator defines a problem, gathers data, analyzes the facts, and determines and evaluates solutions

Weakened

The investigation process is __________ if the three phases are not performed thoroughly

1. Engineering 2. Worker 3. Management 4. Combination

What are the four levels of accountability

1. Gain knowledge 2. Analyze the knowledge 3. Develop corrective actions

What are the three phases of accident Investigation?

Analyze the knowledge

What happened?

Accident sequence

When an investigator develops scenarios that help to reveal what happened before and during the accident

Investigator

When taking an analytical approach, who interviews people involved in the accident, takes pictures, and uses other investigative techniques to analyze an accident

Investigator

Who develops scenarios that help to reveal what happened before and during the accident

Analyst

Who will know as much as possible about what caused the accident and will be able to recommend corrective actions

complexity of the accident

a tenet of accident investigation is that the length of time it takes to conduct an accident investigation is determined by

layered investigation

keeping types of causes separate