Accident Investigation - PowerPoint Presentation

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Accident Investigation

DATA ANALYSISPhase 3

Updated 2 July 2014Slide2

Analytical Process

The prevention of accidents and the conservation of resources is the primary purpose of accident investigation. Analysis of the data becomes the basis for the Findings and Recommendations.

Data AnalysisSlide3

Concept:

The reason people make errors, material fails, environmental conditions contribute or injuries occur in an accident are the keys to accident prevention. (DA PAM 385-40, page 31)Data AnalysisSlide4

Scope: The accident analysis function inherently requires that the accident data be examined in detail to determine how man, machine and environment interacted. (DA PAM 385-40, page 31)

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Objectives:

(a) Chronology of Events:(b) Identify human errors, material failures and or environmental conditions that caused or contributed to the accident (what happened)(c) Identify system inadequacies that caused or permitted errors/failures/injuries to occur or environmental factors to contribute (why it happened)

(d) Document adequacy of LSE/PPE

(e) Provide corrective actions

(what to do about it)

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Analytical Process:

Once accident investigation data has been collected, it must be properly analyzed in order to determine the relationship between what happened and why it happened.The reason is more important than the event. If the system inadequacies can be dealt with effectively, the probability of similar inadequacies causing future accidents and injuries may be reduced.

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NOTE: The analysis of the accident is the Board's Consideration of why things happened. It should consider all facts or data in the Narrative, 2397 or 285 series forms, and supporting documentation. Slide8

NOTE:

Informal data analysis starts after data collection has begun, perhaps the third day or so and continues through deliberations.Slide9

Analytical

Process:The analysis is dependent on the quality of the data acquired and how it is categorized. Obviously, little or poor data may not identify a breakdown within the system elements. To ensure quality:Work group sharing

: The tasks of data collection as well as the information gleaned as a result, must be shared. The investigation team should meet daily to accomplish this.

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Analytical

Process:The benefits are:The analysis begins early in the investigation and perpetuates throughout the entire investigation.

Mutual progress

: Often the disclosure of facts by one group may have a great deal of impact on another group. Each group should also present any difficulties in obtaining data.

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Analytical Process:

The benefits are:Reduce Redundancy: That is, to ensure individuals or work groups are not each working to discover the same facts.

Resolve Conflicts

: Conflicts of information between individuals or work groups and to resolve conflicts of outside influences.

Redirect Efforts

: New information or developments of old information can produce a redirection of efforts.

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Analytical Process:

Limits of analysis: The analysis is not necessarily limited to the field investigation and may extend beyond the tenure of the board, i.e., USACRC and other managers of resources.

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The

analysis process permits the board to reach a consensus on such analytical objectives as:Chronology of events: A precise time table of events leading up to and during the accident. It may even be necessary to go further into rescue efforts if they were handled poorly.Identification of human errors, materiel failures, environmental factors

which may have caused or contributed to the accident. The in the 3W process.

“WHAT HAPPENED”

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The

analysis process permits the board to reach a consensus on:Adequacy of safety engineering. Protection provided by machine design and personal protective devices/equipment. You must be able to conclude how injury occurred or contributed to the cause of death.

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The

analysis process permits the board to reach a consensus on:System inadequacies which caused or contributed to the accident. The “WHY” of the 3W process. More than one system element can been present to produce each error or failure in the accident. The board must evaluate the cause and effect relationship of the system inadequacies to the errors or failures.

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The

analysis process permits the board to reach a consensus on:Corrective actions or remedial measures (recommendations) having the best potential for remedying the system inadequacies. The “WHAT TO DO

ABOUT IT”

of the 3W process. Recommendations must be

cost effective

, targeted to the correct level of command and mission oriented.

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NOTE

: At some point during the investigation, the data collection phase is completed. At this time no remaining sources of information are available or expected. The

requirement now is to analyze the data and to structure the results into a format that

clearly shows the interrelationship between the cause related errors/failures and the system inadequacies

which caused or permitted them to occur.

The

method used for this more formal analysis is the board deliberations. Slide18

Deliberations

:Collective Group: All board members or the individual investigator, using the 3W process, reviews and finalizes the analysis.Facilities: Private area with chalkboard, butcher paper or other display media, telephone, and nearby typing support.

Positions/Presentations

: The president will chair the deliberations. Each member will present the problems he/she discovered.

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Board RoomSlide22

Data CollectionSlide23

Data CollectionSlide24

Data OrganizationSlide25

Deliberations:

Deliberation secession:The board president is responsible for the supervision of deliberations. First, determine all abnormalities discovered during the data gathering process by going through a process in which the individual areas are written on a chalkboard or butcher chart and abnormalities in each area are listed. A listing of individual areas is provided in the USACRC

Handbook

for

accident investigation.

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HFACSSlide30

NOTE: During this phase of the deliberations, do not try to determine cause factors; just list all the problems and abnormalities noted during the data gathering process.Slide31

Deliberations:

Second, after ensuring that all abnormalities and problems have been listed, go to an event chart to determine actual cause factors. Start with the mishap and go back in time and list the events leading up to the mishap, then go forward in time for egress and rescue. As the abnormalities are posted to the event chart the board discusses the relationships and importance of each.

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Timeline

Data SourcesWitness interviewsAircraft MDRs & FDRs

ATC logs and tapes

Range control logs and tapes

Operations logs

Crash rescue logs & dispatch

MEDEVAC logs and

AARs

Personal effects (Analog watches)

Aircraft clock (Analog)

SMODIM data

Radar facility

Mission planning data

Crewmember dataSlide34
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Deliberations

:After completion of the event chart, one should be able to write the findings that were contributory to the mishap from what is listed on the chart. When all of the events have been listed on the chart, go back to your original list and cross out those things that are now on the event chart.

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HUMAN

FACTORSSlide38
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NOTE: The remaining abnormalities will either be present but not contributing factors, comments in the analysis, or discarded as insignificant items. The Board should discuss each of the abnormalities and based on this discussion, determine the category of finding in which they belong. Slide40

NOTE: Credibility: The analysis portion of the written narrative provides credibility to the report. It provides the reader with a clear picture of all things considered during the investigation and shows the reasoning behind the investigators' conclusions.Slide41

Written analysis:

Complete the analysis and ask these questions. Does the analysis: Stand on its own? It should contain minimal cross referencing to other documentation. Do not restate the history but do put enough information to address the unsafe acts and system problems.

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Written analysis:

Complete the analysis and ask these questions. Does the analysis: Explain what happened, to include how injuries occurred? Cause and Effect relationship.Identify the cause related

errors and failures?

(human errors, materiel failures or environmental factors).

Identify the system inadequacies?

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The

analysis paragraph should be written so it supports the findings (usually written before the F&Rs). For assistance with this paragraph see DA Pam 385-40 and the Accident Investigators Handbook. All three areas of the investigation should be addressed in analysis (human, material, environment) as causal or not causal in the accident.

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Simple Approach

Create time line of significant events

List all anomalies found during data collection

Discuss each anomaly and its relationship to the accident

Categorize the anomalies

Write analysis of the data

Write the Findings and Recs

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PRACTICAL

EXERCISE!Slide46

Read history of Accident

Conduct group deliberations to determine task error (TE) and system inadequacy(ies) (SI) Refer to Tables B-2 and B-5 in DA PAM 385-40 for list of TE and SI (s)Each group will brief class on their task error and system inadequacySlide47
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QUESTIONS?

Data Analysis