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1NavalSafetyCenterSchoolOfAviationSafetyHumanFactorsPhotographyWitnessesRecordsMaterialFactorsHumanFactorsPhotographyWitnessesRecordsMaterialFactorsEvidenceAnalysisConclusionsRecommendationsReportingEvidenceAnalysisConclusionsRecommendationsReportingAccidentInvestigationTrainingAccidentInvestigationTrainingPresentationTime:Approximately1.5hrsNote:Thispresentationwascreatedtobea“generic”guidetoaviationorganizationaccidents.Assuch,sometopicdiscussionsandexamplesmayextendbeyondthescopeofyourstudents’investigationrequirements.Discussionofallmaterial,evenifonlybrieflymentioned,ispreferabletoskippingover“extra”materialbecauseitprovidesstudentswithadditionalinsight,confidence,andresourcestoaccomplishtheirowninvestigations.Accidentinvestigationisbothanartandascience.Laboratorytestingofmaterials,failuremodes,sampleanalysis,etc.arescientificprocessesthatprovideuseabledata.Butwhichitemsdoyoutest?Youmaywanttotesteverything,butevenbringinganentireaircraftintoalabwillnotrevealmuchmorethanWHAThappenedtotheaircraft(e.g.,itbrokeinaparticularway)viceWHYithadanaccident.Alabmayalsodiscoverthatapartfailedduetofatigue.Butwhy?Detectiveworkisnecessarytodetermineifthepartwasdesignedimproperly,maintainedimproperly,orabusedtoeitherstartthefatiguecrackorallowittogounnoticed,orworse,noticedbutnotcorrected.Foronlythosefewoptions,therearecountlessadditionalWHYs.Wasitdesignedormanufacturedimproperlybecauseofpoorstaffing,organization,andQAatthemanufacturer?Orwastherealocalmaintenanceproblemwithlighting,inadequateequipment,andtimeconstraints?Wasthereacultureofindifferencetoqualityandstandards?Thoseanswersarenotfoundinalab.TheinvestigatormustfindtheanswertotheWHYsatthesource.Interviews,photography,andaneyefordetailarejustthebeginning.Thispresentationwillprovidethebeginninginvestigatorwithbasicconceptsandskills,aswellas,heightenawarenessonthenecessitytoconductthoroughinvestigationsandreportthemadequately.2�Identifyhazards(accidentcausalfactors)andproviderecommendationswhichwillpreventoccurrenceorrecurrence�Identifyotherhazardsthatincreasedthelevelofinjury/damage,butwerenotaccidentcausefactors�Identifyhazards(accidentcausalfactors)andproviderecommendationswhichwillpreventoccurrenceorrecurrence�Identifyotherhazardsthatincreasedthelevelofinjury/damage,butwerenotaccidentcausefactorsWhyDoWeInvestigate?Whydoweinvestigate?Toeffectivelydiscoverthehazardsthatledtotheaccidentandtopreventtheirrecurrenceinafutureaccidentorincident.Inthecourseofthatinvestigation,additionalhazardswhichincreaseddamageandinjury(inadequatecrashworthysystems,systemsafeguards,rescueteamresponse,etc.)canalsobecorrectedtomakefutureaccidentslesscostly.AninvestigatorwillmostlikelydiscovermanyotherhazardsduringthecourseofaninvestigationwhichmayhaveNOTHINGtodowiththeaccident.TheseadditionalhazardsdoNOTbelongintheaccidentreport,buttheymustalsonotbeignored.Theyshouldbeaddressedinaseparatehazardreportorcorrectedinsomeotherfashion.3AllAccidentsarePreventableTherefore,theeliminationofhazardsmeansthatALLACCIDENTSarepreventable.Therefore,theeliminationofhazardsmeansthatALLACCIDENTSarepreventable.Individualhazardsarepreventable.Individualhazardsarepreventable.Accidentsarecausedbymultiplehazards.Accidentsarecausedbymultiplehazards.Important:Allaccidentcausefactors(hazards)areassumedtobecontrollablebyhumans.Assuch,theycanbecorrected,mitigated,ande...