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 , 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 , 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 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

Timeline Data 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

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 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 Create time line of significant events List all anomalies found during data collection List all anomalies found during data collection Discuss each anomaly and its relationship to the accident Discuss each anomaly and its relationship to the accident Categorize the anomalies Categorize the anomalies Write analysis of the data Write analysis of the data Write the Findings and Recs Write the Findings and Recs Data Analysis

PRACTICAL EXERCISE!

 Read history of Accident  Conduct group deliberations to determine task error (TE) and system inadequacy(ies) (SI)  Refer to Tables B-2 and B-5 in DA PAM for list of TE and SI (s)  Each group will brief class on their task error and system inadequacy

QUESTIONS? Data Analysis