The Accident Investigation Process

Accident investigation is the process to gather facts about accidents / incidents. The process does also apply to other unwanted events and their consequences, such as quality problems, customer complaints, etc.

Accident investigation and learning from what went wrong really is a problem solving process, starting with the way we realize that there is a problem: losses, damage, harm etc.

The problem solving procxess is rather generic - translated to the field of risk management is may look like this:

Accident investigation is a disciplined, methodical process of examination to establish how, when, and where an accident occurred with the purpose of determining why the accident occurred. We base ourselves on the definition of an accident as an undesired event, resulting in physical harm to people and/or damage to property, that usually resulted from contact with a source of energy above the threshold limit of the body or structure.

Essential to the examination of an accident is the consideration that an activity is comprised of four subsystems. These are people, equipment, material and the environment. Examining the interface of these elements leads through identification of the immediate causes to basic causes and the origins of accidents in management errors and deficiencies. Because basic causes are rooted in management's lack of contral, it is essential that investigation of accidents be a management function, beginning with the first line manager, the supervisor.

Proper accident investigation is the basis for cause analysis and for taking actions to prevent any secondary accidents as well as recurrence of similar events.

That process contains three main steps that form the foundation of improvement:

1. Plan - have a plan to carry our investigations
2. Train - people to carry out investigations effectively with optimum results
3. Do - carry out investigations according to plan, evaluate the quality of the investigation and improve

These steps need to be carried out in the order 1 - 3. Further improvement comes from evaluations that are part of step 3 "Do".

The quality of the investigations - the investigation performance - rest on those three foundation pillars. This can be visualized by the Platform model presented below:

The level of performance - be it in accident investigation or other business management areas - rests on the three pillars, columns or "legs": Plan - Train - Do. The better these are developed the higher the platform, the performance level. These legs should be developed in balance; if not the performance level will not be stable.

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