ACCIDENT INVESTIGATION BOARD DELIBERATIONS SUPPLEMENT (DA Pam 385-40)

Slides:



Advertisements
Similar presentations
1 Air Traffic Quality Assurance Program The Federal Aviation Administration Presented By: Gary D. Romero.
Advertisements

Supplemental Figure 1 A No. at risk T T T
Accident Investigation for Supervisors
1 ATS Incidents Reporting and Investigation Teams The Federal Aviation Administration Presented By: Rick Baker.
Accident Investigation. What is an Accident? n An unintended happening, mishap. n Most often an accident is any unplanned event that results in personal.
The Army Safety Program
Alison Standfast 31 January EMPLOYERS’ LIABILITY AND PUBLIC LIABILITY CLAIMS.
CONDUCT PREVENTIVE MAINTENANCE CHECKS AND SERVICES TSP NO: 091-O-2572
Integration of Quality Into Accident Investigation Processes ASQ Columbia Basin Section 614 John Cornelison January 2008.
Accident Investigation: The “3W” Process Gary D. Braman, CSP Sikorsky Aircraft Corporation A Presentation to the Tennessee Valley Chapter American Society.
Accident Investigation Preparation and Preliminary Examination
Management Safety Policy and Decisions Personal Factors Environmental factors Unsafe Act Unsafe Condition Unplanned Release of Energy and/or Hazardous.
Incident Investigation. An incident is any unplanned event that results in personal injury or in property damage The failure of people, equipment, supplies,
Learning Objectives  Recognize the need for an investigation  Investigate the scene of the accident  Interview victims & witnesses  Distinguish.
ACCIDENT INVESTIGATION
P449. p450 Figure 15-1 p451 Figure 15-2 p453 Figure 15-2a p453.
UNIT CREST UNIT LOGO 1 UNCLASSIFIED/FOUO UNIT MOTTO UNCLASSIFIED/FOUO COMMAND OUTBRIEF AH-64D, DD November YYYY (Insert Company, Battalion) (Insert Location)
Better Accident Investigations Presented by QBE Loss Control Services.
MICS Data Processing Workshop Multiple Indicator Cluster Surveys Data Processing Workshop Data Quality Tables.
Accident Investigation.
Objectives  Understand what a Loss Incident is.  Know the real cost of a Loss Incident.  Understand the Causes of a Loss Incident.  Understand what.
Incident Reporting Procedure
Guidance Notes on the Investigation of Marine Incidents
1. Objectives  Describe the responsibilities and procedures for reporting and investigating ◦ incidents / near-miss incidents ◦ spills, releases, ◦ injuries,
1 UNCLASSIFIED Office of the Director of Army Safety (ASO) & US Army Combat Readiness Center (USACRC) UNCLASSIFIED ACCIDENT INVESTIGATION 101.
Accident Investigation DATA ANALYSIS Phase 3 Updated 2 July 2014.
1 UNCLASSIFIED Office of the Director of Army Safety (ASO) & US Army Combat Readiness Center (USACRC) UNCLASSIFIED Deliberations Brief Deliberations Brief.
Why Do We Have Accidents?
The Air Accidents Investigation Branch Keith Conradi Chief Inspector of Air Accidents.
Michael Barbadora Mrs. Kovar English September 2015.
Prepared by the Honor Committee Honor in Everyday Life HONOR 4-6 Honor in everyday life.
UNIT CREST UNIT LOGO 1 UNCLASSIFIED/FOUO UNIT MOTTO UNCLASSIFIED/FOUO COMMAND OUTBRIEF AH-64D, DD November YYYY (Insert Company, Battalion) (Insert Location)
Accident Investigation. What is an Accident? n An unintended happening, mishap. n Most often an accident is any unplanned event that results in personal.
Presented to: By: Date: Federal Aviation Administration AIRWORTHINESS Positive Safety Culture Failure to Follow Procedures 1 R1.
Mr. Bob Hahn Associate Director, School of Aviation Safety Naval Aviation Schools Command NAS Pensacola MISHAP PREVENTION EDUCATION IN NAVAL AVIATION.
ACCIDENT INVESTIGATION How, why,when,where???? Arunachalam Manager, MGVTS.
Why Similar Accidents Keep Duplicating Themselves Prevent Recurrence of The Goal: Prevent Recurrence of Similar Accidents and Injuries.
Root Cause Analysis Systems Safety Technique used to identify the “Root Causes” of accidents A root cause is the most basic cause for a accident that can.
Human Error Reduction – A Systems Approach.
Accident Investigation
Multiplication table. x
JO EHS Statistics Actual Limit JO Employees Contractors
GE 6757 TOTAL QUALITY MANAGEMENT
Where We Are OVERVIEW Lesson 1: Course Overview
آشنايی با اصول و پايه های يک آزمايش
Incident Reporting And Investigation Program
Figures & Tables from the textbook.
Loss Control.
Accident Investigation
JOB HAZARD ANALYSIS (JHA)
WHAT IS THE SCIENTIFIC METHOD?
Air Traffic Quality Assurance Program
Accident Investigation
5 × 7 = × 7 = 70 9 × 7 = CONNECTIONS IN 7 × TABLE
5 × 8 = 40 4 × 8 = 32 9 × 8 = CONNECTIONS IN 8 × TABLE
The Federal Aviation Administration Presented By: Rick Baker
4 × 6 = 24 8 × 6 = 48 7 × 6 = CONNECTIONS IN 6 × TABLE
5 × 6 = 30 2 × 6 = 12 7 × 6 = CONNECTIONS IN 6 × TABLE
Figure 11-1.
Working at Height.
Loss control leadership 101
10 × 8 = 80 5 × 8 = 40 6 × 8 = CONNECTIONS IN 8 × TABLE MULTIPLICATION.
3 × 12 = 36 6 × 12 = 72 7 × 12 = CONNECTIONS IN 12 × TABLE
Figure Overview.
Figure Overview.
5 × 12 = × 12 = × 12 = CONNECTIONS IN 12 × TABLE MULTIPLICATION.
Accident Investigation
5 × 9 = 45 6 × 9 = 54 7 × 9 = CONNECTIONS IN 9 × TABLE
Accident Investigation.
3 × 7 = 21 6 × 7 = 42 7 × 7 = CONNECTIONS IN 7 × TABLE
Presentation transcript:

ACCIDENT INVESTIGATION BOARD DELIBERATIONS SUPPLEMENT (DA Pam )

1. Group Anomalies into three categories: Environmental, Material, or Human 3. Refer to DA PAM , Appendix B to determine a Task Error for the anomaly (One per finding): Table B-1: Aviation Human Task Errors Table B-2: Ground Human Task Errors Table B-3: Material Failures/Malfunctions Table B-4: Environmental Conditions 4. For human task errors refer to DA PAM , Figure 2-1 in conjunction with Table B-5 to determine root cause/system inadequacy (there can be multiple system inadequacies). 2. Review anomalies to determine if they were present in the accident. Then analyze to determine if they were: Present & Contributing (PC) - Contributed to the accident. Present but not Contributing (PBNC) - Did not contribute, but could cause an accident in the future. Suspected PC- Suspected to have contributed to the accident. Special Observation (SO) - In no way contributed, but the Board determined the chain of command should be informed (positive or negative) Freebie (F) - Minor discrepancies that are brought to the chain of command, but are not in the final report. 5. Record the following information to assist in writing the finding using Tables 3-1 or 4-2 in DA PAM:  When and where the mistake/error occurred  Equipment & individual (by duty position) involved  Identify the mistake/error in relation to a deviation from a standard, directive, or common practice governing the performance of the task 6. Develop Recommendations using DA PAM , Table B-6

MaterielHuman Environment CodeAnomalies (Deficiencies & failures)ReferenceCodeAnomalies (Errors - Failures - Deficiencies)Reference CodeConditions (Unforecast or unavoidable)Reference P&CPresent and contributing PBNCPresent but not contributing P&C S/DPresent and contributing to severity of injury or damage OObservation FFreebee Deliberations Worksheet