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
