Incident
Investigation -- Tips, Techniques & Trivia
Greetings:
Here’s
some feedback about last month’s newsletter. Your comments,
positive or negative are always welcomed.
- I
have asked you several times to stop sending me email messages.
Please do so.
(This was the first message I received from this person. If
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“unsubscribe” feature at the bottom of the letter.
I don’t like SPAM, and am certain you feel the same way.
For the past three years all additions to my mailing list are
at the recipient’s request.)
On
a more positive note. . .
- xxxx
in the Safety Dept. suggested I subscribe to your newsletter.
Could you please add me?
- Thank
you so much for your newsletter. I recently assumed duties,
but not the title, for risk management at xxxxxx. Your newsletter
is so practical. It will make my life much, much easier. I
appreciate your effort.
Jeff
Root Cause Analysis: Will It Find the
Weak Link?
Robert J. Latino, Reliability Center,
Inc.
(The following are excerpts from an article
on root cause analysis as it relates to the world of maintenance.
The author has some interesting insights that are applicable to
the world of investigation.)
Have you ever conducted a comprehensive, disciplined
and accurate root cause analysis only to find that the recommendations
fell on deaf ears, or worse, nobody followed through on the approvals
that were granted? Getting to the root cause is the easy part.
Getting something done to eliminate them is a different matter.
It is ironic that we see average returns for root
cause analysis in the neighborhood of 800 to 1,000 percent, yet
no one believes these figures because they are considered too
“pie-in-the-sky.”
If management questions the economic feasibility
of implementing the solutions, then the original failure was not
worthy of root cause analysis. Turf protection, bonus incentive
systems, retirement dates and future promotional opportunities
are some of the issues we run into when trying to get management
to act on latent roots.
The On-Scene Investigation
By Brian F. Finnegan
(The following is about aircraft accident
investigation. The first paragraph about a broken jar and how
we pick up the pieces(evidence) really caught my attention, and
the article holds an important message for us in the workplace
investigation world.)
Imagine you are barefoot and a large glass jar
has been knocked from the shelf onto the hard ceramic floor, shattering
into thousands of pieces. There certainly is a central point where
the largest pieces are, but radiating outward from this central
area, probably in one direction more than another, are the many
pieces of the jar with their innumerable sharp and piercing edges.
Now imagine how you, still barefoot, will go about
cleaning it up and you will have the general idea of how to approach
the scene of an aircraft accident. First, go slow. Start at the
perimeter of the debris field and circle the site. Be very observant,
noticing tree and ground scars, paper and wreckage location, etc.
Document well with photographs, sketches, and notes. Use a tape
recorder to explain your thoughts. Pay close attention to detail
as you move closer to the wreckage.
The link below will take you to the article. Scroll
down as it's about the sixth article of the series.
To
view complete article. . .
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