Incident
Investigation -- Tips, Techniques & Trivia
Greetings:
Here’s some feedback about last month’s newsletter.
Your comments, positive or negative are always welcomed.
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messages. Please do so.
(This was the first message I received from this person. If
you do not wish to receive my newsletter please use the automatic
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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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