Accident investigations what happened

In an accident investigation the strengths may he called reliabihty/resihence as observed , the weaknesses may be called accidents or incidents as observed , the opportunities to improve resihence may be called resihence engineering and the threats may be called threats/risks in the future . Strengths and weaknesses have been identified in the past, opportunities and threats may happen in the future. This taxonomy may be useful when discussing focus of the accident analysis, is the focus on what went wrong or looking at positive factors in the accident ... 

The culvert example is not used for accident investigation (of what actually happened that day), but as a basis for analyzing interdependencies in the possible chains of events of such a scenario. 

When preparing an accident investigation report, use the analysis results to make specific and constructive recommendations. Never make general reconunendations just to save time and effort. Use previously drafted sequence of events to describe what happened. Photographs and diagrams may save many words of description. Identify clearly if evidence is based on facts, eyewitness accounts. 

When accidents are not reported, their causes usually go uncorrected. This allows the chance for the same accident to happen again. Every accident, if properly investigated, serves as a learning experience for the people involved. However, investigations should not become a mechanical routine. They should strive to establish what happened, why it happened, and what must be done to prevent a recurrence. An accident investigation must be conducted to learn the facts, not to place blame. 

Despite their complexity, most accidents are preventable by eliminating one or more causes. Accident investigations determine not only what happened, but also how and why. The information gained from these investigations can prevent the recurrence of similar or perhaps more disastrous accidents. Accident investigators are interested in each event as well as in the sequence of events that led to the accident The accident type is also important to the investigator. The recurrence of accidents of a particular type or those with common causes show areas needing special accident prevention emphasis. 

Accidents should be investigated as soon as possible after they happen. The more time that passes before questioning personnel and witnesses involved, the greater the risk of not getting an accurate story of what happened and why. The injured... 

First, we can prevent them by knowing what caused the accidents to happen in the first place. Accident investigators perform that task. The accident investigator determines the direct, indirect, and basic causes of an accident. But prevention does... 

Using the company s accident investigation forms, the first thing to do in analyzing the accident is to read the narrative and visualize what happened. Often, the report is sketchy, but most of the time you will be able to draw on your experience to read between the lines and get the picture. Once you have visualized the situation and what occurred, then ask What could have prevented this accident To help determine the appropriate preventive measures, make use of the list of physical barrier analysis statements. The following statements refer to each of the four types of physical barriers. For each type, there are four possibilities. Select the one that best represents a valid opinion of the accident. 

What happened The investigation report should describe the accident, the injury sustained, eyewitnesses, the date, time, and location of the accident. 

The purpose of both accident and near miss incident investigation is to carry out an investigation into the undesired event, to determine what happened, and what can be done to prevent a similar event recurring. If positive preventative measures are not taken after an accident or near miss incident, the probability of recurrence is great. The investigation procedure would lead to the root causes of the event and help determine what steps should be taken to prevent a similar accident or near miss incident. 

The extent of the loss should not determine who should carry out the investigation. Past experience has shown that once there are fatalities, multiple fatalities, or great financial loss as a result of an accident, only then does top management get involved. What should determine participation in the near miss incident or accident investigation procedure is the potential for loss of the event, or what could have happened under slightly different circumstances ... 

All accidents that cause injury, damage, or business loss must be investigated to determine what happened so that preventative measures can be initiated to prevent a recurrence. All near miss incidents that have high potential to cause loss should receive the same attention as accidents and also should be thoroughly investigated in the same way and with the same gusto as accidents. 

The initial work a board performs largely determines the outcome of the investigation. If the board is sloppy, the results could be inconclusive, incorrect, or even misleading. Crucial accident evidence and information could be lost forever, and it might become impossible to truly determine what happened even if a new board is formed. 

Everyone who is involved with efforts to improve safety just knows that learning should be based on accidents, on things that have gone wrong. Accidents are accepted as opportunities to learn, specifically to find out what should be done to make sure that the same - or a similar - accident will not happen again. Since accident investigations often are limited by time and resources, there is a tendency to look at the accidents that have serious consequences and leave the rest to be dealt with later... 

MORT can be used in all major accident and incident investigations, not only to discover the important immediate factors surrounding an accident ( what happened ) but also to describe the management control factors ( why it happened ) involved. MORT helps investigators to isolate quickly key accident contributors. 

To be effective, accident investigation should have a plan to be executed by management and other trained individuals. These plans should be designed to satisfy corporate policies and legal issues. The plan should always produce an investigation to determine the cause of the accident and what measure must be taken to prevent it from happening again. 

Accident investigation should be an integral part of your written safety and health program. It should be a formal procedure. A successful accident investigation determines not only what happened, but also finds how and why the accident occurred. Investigations are an effort to prevent a similar or perhaps more disastrous sequence of events. You can then use the resulting information and recommendations to prevent future accidents. 

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