Accident Investigation DATA ANALYSIS

Phase 3

Updated 2 July 2014

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 Analysis

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 Analysis

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)

Data Analysis

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)

Data Analysis

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.

Data Analysis

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.

NOTE:Informal data analysis starts after

data collection has begun, perhaps the third day or so and continues

through deliberations.

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.

Data Analysis

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.

Data Analysis

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.

Data Analysis

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.

Data Analysis

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”

Data Analysis

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.

Data Analysis

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.

Data Analysis

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.

Data Analysis

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.

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.

Data Analysis

Board Room

Data Collection

Data Collection

Data Organization

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.

Data Analysis

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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.

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.

Data Analysis

TimelineData Sources

Witness interviews Aircraft 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 data

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.

Data Analysis

3/2/2002 AIBP-BII-21

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.

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.

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.

Data Analysis

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?

Data Analysis

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.

Data Analysis

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

Data Analysis

PRACTICALEXERCISE!

Read history of AccidentConduct 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 inadequacy

QUESTIONS?

Data Analysis