a. Why the accident occurred. b. A likely sequence of events and probable causes (direct, indirect, basic). 8. Check each sequence against the data from step 7. 9. Determine the most likely sequence of events and the most probable causes. 10. Conduct a post-investigation briefing. 11. Prepare a summary report, including the recommended actions to prevent a recurrence. Distribute the report according to applicable instructions. An investigation is not complete until all data are analyzed and a final report is completed. In practice, the investigative work, data analysis, and report preparation proceed simultaneously over much of the time spent on the investigation. II. Fact Finding Procedures Gather evidence from many sources during an investigation. Get information from witnesses and reports as well as by observation. Interview witnesses as soon as possible after an accident. Inspect the accident site before any changes occur. Take photographs and make sketches of the accident scene. Record all pertinent data on maps. Get copies of all reports. Documents containing normal operating procedures, flow diagrams, maintenance charts, or reports of difficulties or abnormalities are particularly useful. Keep complete and accurate notes in a bound notebook. Record pre-accident conditions, the accident sequence, and post-accident conditions. In addition, document the location of victims, witnesses, machinery, energy sources, and hazardous materials. In some investigations, a particular physical or chemical law, principle, or property may explain a sequence of events. Include laws in the notes taken during the investigation or in the later analysis of data. In addition, gather data during the investigation that may lend itself to analysis by these laws, principles, or properties. An appendix in the final report can include an extended discussion. III. Change Analysis As its name implies, this technique emphasizes change. To solve a problem, an investigator must look for deviations from the norm. Consider all problems to result from some unanticipated change. Make an analysis of the change to determine its causes. Use the following steps in this method: 1. Define the problem (What happened?). 2. Establish the norm (What should have happened?). 3. Identify, locate, and describe the change (What, where, when, to what extent). 4. Specify what was and what was not affected. 5. Identify the distinctive features of the change. 6. List the possible causes. 7. Select the most likely causes. IV. Report of Investigation
a. Why the accident occurred. b. A likely sequence of events and probable causes (direct, indirect, basic). 8. Check each sequence against the data from step 7. 9. Determine the most likely sequence of events and the most probable causes. 10. Conduct a post-investigation briefing. 11. Prepare a summary report, including the recommended actions to prevent a recurrence. Distribute the report according to applicable instructions. An investigation is not complete until all data are analyzed and a final report is completed. In practice, the investigative work, data analysis, and report preparation proceed simultaneously over much of the time spent on the investigation. II. Fact Finding Procedures Gather evidence from many sources during an investigation. Get information from witnesses and reports as well as by observation. Interview witnesses as soon as possible after an accident. Inspect the accident site before any changes occur. Take photographs and make sketches of the accident scene. Record all pertinent data on maps. Get copies of all reports. Documents containing normal operating procedures, flow diagrams, maintenance charts, or reports of difficulties or abnormalities are particularly useful. Keep complete and accurate notes in a bound notebook. Record pre-accident conditions, the accident sequence, and post-accident conditions. In addition, document the location of victims, witnesses, machinery, energy sources, and hazardous materials. In some investigations, a particular physical or chemical law, principle, or property may explain a sequence of events. Include laws in the notes taken during the investigation or in the later analysis of data. In addition, gather data during the investigation that may lend itself to analysis by these laws, principles, or properties. An appendix in the final report can include an extended discussion. III. Change Analysis As its name implies, this technique emphasizes change. To solve a problem, an investigator must look for deviations from the norm. Consider all problems to result from some unanticipated change. Make an analysis of the change to determine its causes. Use the following steps in this method: 1. Define the problem (What happened?). 2. Establish the norm (What should have happened?). 3. Identify, locate, and describe the change (What, where, when, to what extent). 4. Specify what was and what was not affected. 5. Identify the distinctive features of the change. 6. List the possible causes. 7. Select the most likely causes. IV. Report of Investigation
Employee_Policy_and_Procedures-2-1.docx