In-depth accident investigation

Barrios, M. J., Aparicio, A., Davila, A., Miguel, J. L. D., Modrego, S., Olona, A., et al. (2009). Evaluation of the effectiveness of pedestrian protection systems through in-depth accident investigation, reconstruction and simulation. In 21st International Technical Conference on the Enhanced Safety of Vehicles (ESV 2009), No. 09-0316. 

Multidisciplinary in-depth accident investigations are used to provide detailed knowledge about traffic accidents. An investigation team consists of experts in different areas. They apply a documented investigation method in order to... 

In using in-depth accident investigation techniques, the investigators have to address methodological issues such as ... 

Experiences show that in-depth accident investigations provide important experience data from traffic accidents for use in design of vehicles. There are several examples of safety features that originate from these investigations. Many of these featnres have been taken over by the legislators and made mandatory for all trnck manufacturers. 

Root causes must be identifled and appropriate corrective action implemented. The accident analysis may be performed by the SSWG and/or by other boards of investigation, but the necessity for systematic, in-depth accident analysis is an integral part of the system safety effort. 

Another example for an in-depth accident data base is the Pedestrian Crash Data Study (PCDS) from the US [29] (which is also described in Sect. 5.2.1) or accident investigations carried out by vehicle manufacturers. The latter ones have a very high level of detail but suffer even more from biases due to low case numbers, model selection criteria or geographic effects [16]. 

The approach selected here for in-depth accident and near-accident investigation should not be confused with the police investigations of such events. It differs from the police investigations in that the latter aim to discover which laws or company procedures have been violated, who violated them and who is liable. 

In recent years, from investigation on a large number of enterprises, more and more enterprises are starting to make zero accident concept as one of their safety management concepts, and establish a zero accident objective as their highest safety objective, such as DuPont, Eluor, Alcoa, Dow, Intel, Motorola, Lonza (Guangzhou), the Rainbow Group, Australian Coal Association and so on. The safety performance of these enterprises is well known, however, the relationship between achieved safety performance and zero accident concept has not been studied in depth, and this paper will carry on theoretical and empirical research on this issue. 

W. H. Heinrich from America had attempted amore in-depth study on near miss. He investigated more than 5,000 injuries and found that in 330 similar accidents 300 accidents caused no injuries, 29 cases caused minor injuries along with 1 caused serious injury. That is to say, serious injury, minor injury and no injury accident number ratio is 1 29 300, which is the famous Heinrich law, called the accident triangle, as shown in Figure 3. 

Perform in-depth incident and accident investigations, including all systemic factors. Assign responsibility for implementing all recommendations. Follow up to determine whether recommendations were fully implemented and... 

The purpose of MORT analysis is to provide a systematic tool to aid in planning, organizing, and conducting an in-depth, comprehensive accident investigation (or inspection, audit, or appraisal) to identify those specific control factors and management system factors that are less than adequate and need to be corrected to prevent recurrence of the accident (or to prevent other undesired events). 

For most of the tests and accidents, raw data on debris density are presented as debris mass density in kg per m. For the China Lake test and the Steingletscher accident, an in-depth investigation of this relationship was performed. The surveyed data showed that for 1 kg of rock mass, 0.8 to 1.4 pieces of hazardous debris result (see also Fig. 26.17). For the development of the new model, an average value of one piece of hazardous debris per one kg of rock mass was finally assumed. 

Content analysis was utilised in this research, which proved usable in this kind of study. The method enables processing material (the fatal investigation reports) comprehensively and in depth. The work system framework seems to be suitable for studies of a various kinds related to work. The accident factors were able to be placed in the elements of the work system model, but some difficulties occurred. Many of the accident factors, for example, could have been placed in various elements. However, the original plan was to place one accident factor in only one element mainly, this was fulfilled. One significant addition to this study would have been to consider more explicitly the interrelationship of the accident factor for all five elements. It is clear that the number of investigation reports was limited, but... 

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)... 

Appendix 15.2 provides a checklist of headings, which may assist in the collection of information. It is not expected that all accidents and incidents will be investigated in depth and a dossier with full information prepared. Judgement has to be applied as to which incidents might give rise to a claim and when a full record of information is required. All accident report forms should include the names of all witnesses as a minimum. Where the injury is likely to give rise to lost time, a photograph(s) of the situation should be taken. 

An unwanted side effect of using human error to explain accidents is that the level of human error becomes the maximum depth of analysis or the universal root cause. Accident investigations often seem to assume that the processes as such were infallible, or would have been so had the operators not done something wrong. It therefore becomes natural to stop the analyses once a human error had been found. This was elegantly expressed by Charles Perrow in 1984, when he wrote ... 

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