1. Accident Investigation: The “3W” Process Gary D. Braman, CSP Sikorsky Aircraft Corporation A Presentation to the Tennessee Valley Chapter American Society of Safety Engineers February 19, 2009

2. Accident Investigation: The “3W” Process

6. What happened? Human error, material failure/malfunction, or environmental condition that contributed to the accident

7. Accident Investigation: The “3W” Process Why Did it Happen? What caused it? System inadequacy (root cause) or the why the task error occurred. Leader failure. Training failure. Standards/Procedures failure. Support failure. Individual failure.

8. Accident Investigation: The “3W” Process What can be done to prevent it from happening again? The corrective actions that will prevent this type of accident from happening again. All corrective actions recommended must be addressed to appropriate level of management and focus on the “why.”

9. The 3W Process can be used to investigate: Major accidents Minor accidents Incidents Near misses Accident Investigation: The “3W” Process

10. “The Bottom Line” Thoroughly investigating all categories of mishaps, incidents and near-misses saves lives and resources For every major accidents there is an estimated 600 near-misses Accident Investigation: The “3W” Process

15. Questions??? Accident Investigation: The “3W” Process

16. Thank You!!! Accident Investigation: The “3W” Process