Accident investigation elements

One of the origins of this view of error and accident causation is the theory of accident proneness, which tried to show that a small number of individuals were responsible for the majority of accidents. Despite a number of studies that have shown that there is little statistical evidence for this idea (see, e.g., Shaw and Sichel, 1971) the belief remains, particularly in traditional industries, that a relatively small number of individuals accoimt for the majority of accidents. Another element in the emphasis on individual responsibility has been the legal dimension in many major accident investigations, which has often been concerned with attributing blame to individuals from the point of view of determining compensation, rather than in identifying the possible system causes of error. 

But, I need to say that emphasis on some of the safety system elements has varied over the past few years. For instance, we had a strong push for a while to overcome our ergonomics risks, and we ve come a long way. Now, we re concenuating on what we know to be the improvement needed in our accident investigation process, and on our high-risk jobs. 

MORT Safety Assurance Systems by WilMam G. Johnson This text serves well both for incident causation model building and for incident investigation. The accident investigation chapter states that while accident investigation has always been a major element in safety, pre-accident hazard analysis is preferable (p. 347). 

Red—event or factor less than adequate (LTA). Any event, factor, or block of events or factors, that, after thorough examination, has been determined to have less than adequate controls or barriers to prevent a transfer of hazardous energy is colored red on the MORT chart. Caution in the use of this color is warranted since any system elements labeled LTA must be well documented and a recommended course of action provided in the hnal accident investigation report to management. 

An important element of a safety and health program is accident investigation. Although it may seem to be too little too late, accident investigations serve to correct the problems that contribute to an accident and will reveal accident causes that might otherwise remain uncorrected. 

Accident prevention depends to a large degree on lessons learned from accident investigation. We cannot argue with the thought that when an operator commits an unsafe act, leading to a mishap, there is an element of human or operator error. We are, however, decades past the place where we stopped there in our search for causes. Whenever an act is considered unsafe, we must ask why. Why was the unsafe act committed When this question is answered in depth it will lead us on a trail seldom of the operator s own conscious choosing. (56)... 

Applicable legal references and Company Safety Element 4.2 Near Miss/ Accident Investigation. 

For all accidents involving cars/pickups/trucks on company property, in addition to the abovanentioned form, a separate form, the company Vehicle Accident/Damage Report must be completed by company security because without this form outside repairs cannot be done (see Company Element Near Miss Accident Investigation). 

COMMON ELEMENTS OF ELECTRICAL ACCIDENTS/ ACCIDENT INVESTIGATION... 

This list of common elements consciously and conspicuously omits the did not follow safety mles excuse that is seen in some accident reports beeause this excuse is not the real accident cause. If someone did not follow safety rules, there are underlying reasons. The critical point in accident investigation is why the safety rules were not followed. The common elements can provide a ftamework for considering the causes of an electrical shock, injury or contact, and provide a starting point for removing the causes and preventing future electrical accidents. 

The assumptions about decomposition and bimodality in combination lead to the conclusion that the elements or constituents can be described and/or analysed individually. This is, of course, a very convenient assumption to make, since it means that we can deal with the constituents one by one. (The principle is also applied to accident investigations, which usually are done for each accident separately.) To the extent that they do influence each other, this is assumed to happen in a linear manner, cf., below. In other words, the whole is just the sum of the parts, or the whole can be expressed and understood as a (linear) combination of the parts. This principle can be seen as analogous to the ceteris paribus assumption that rules empirical research. Ceteris paribus can be translated as with other things the same or all other things being equal. By invoking the ceteris paribus assumption, it becomes possible to focus on one element or function at a time, since all the others are equal, hence unchanged and with no effect. 

Planned accident investigation within a company or enterprise is used to identify four basic elements ... 

The following elements should be utilized by supervisors for conducting accident investigations ... 

To improve effectiveness, supervisors and other accident investigation committee members should receive training adequate to perform the task for which they are accountable. The training should consist of the following elements ... 

What are the four basic elements that a planned accident investigation can identify ... 

A hazard is a wrapper containing (or describing) all of the latent conditions (or components) necessary to result in a mishap, when the latent factors actualize. And, the hazard wrapper also describes the mishap outcome to be expected. The major difference between a hazard and mishap description is how they are stated a hazard could happen whereas a mishap did happen. In addition, a hazard is stated with all the necessary elements as a potential condition, while a mishap is only stated as the final outcome (which is defined in the hazard statement). It is interesting to note that when a mishap actually does occur, it is the job of the accident investigation team to discover all of the mishap causal factors, which in effect describes the hazard components that should have originally been identified. 

Eigure 5.11 shows the main elements of MORT (Johnson, 1980 Knox and Eicher, 1992). They are displayed as events in a logical tree of, in total, about fifteen hundred basic events. Each event corresponds to a question to be addressed in accident investigations and SHE audits. The MORT diagram is not based on systematic research, but is rather a codified collection of the practical experience and judgement existing at that time. 

The TRIPOD model includes SHE culture elements (Reason, 1991). In an accident investigation, the model is used to classify top management commitment on a scale from 1 (pathological) to 7 (generative-proactive). We will treat this aspect of the TRIPOD model in more detail in Section 6.5. 

All accidents are unique, even accidents which have common root causes (latent failures) and which occur in similar circumstances will have different elements. It is impossible, therefore, to create a universal paint-by-numbers approach to accident investigation. It is, however, possible to identify the crucial elements/steps in a good accident investigation process. One such approach, with... 

It is clear, therefore, that any accident investigation which assigns any cansal element to human error bnt which does not identify what predisposed the error behaviour will lead to remedial actions which are at best, limited and at worst, meaningless. Furthermore, the risk of repeat or similar accidents will usually remain. 

Figure 9.1 outlines a process which enables accident investigation information to be used as a feedback to both specific risk assessments and the risk assessment process. Each of these elements is set out below. 

The first critical element in an accident investigation process is to identify the potential hazard that has been realised. A hazard is defined as anything with the potential to cause harm. In addition to identifying the basic hazard, it is also important to identify hazard triggers. 

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