Posts Tagged ‘Investigation’

Columbia Space Shuttle Accident

Thursday, January 1st, 2009

NASA just released a report titled, “Columbia Crew Survival Investigation Report”. The final report is focused on the technical issues involved in the Columbia space shuttle accident in 2003. The report can be downloaded from http://www.nasa.gov/news/reports/index.html.

To me, the 2003 investigation report by the Columbia Accident Investigation Board is more interesting… the report can be downloaded from the same website above. The 2003 report covered organisational factors that contributed to the accident. As in most major incident investigation reports, safety culture was highlighted as a key contributor. The investigation board also highlighted the relationship with the Challenger accident. Very interesting insights. Worth reading…

Video on fatal fall accident

Thursday, August 14th, 2008

This video discusses a fatal fall accident on an oil rig. Good stuff.

http://www.youtube.com/watch?v=Fw06PXA5Lvw

NIOSH Fatality Assessment and Control Evaluation (FACE) Program

Sunday, March 30th, 2008

NIOSH (U.S.) has a Fatality Assessment and Control (FACE) Program that investigates fatal accidents and make the report available on their website. The reports can be quite useful if you want to develop case studies for safety education purpose. Click here for the website.

Accident investigation methodology

Tuesday, March 11th, 2008

I developed a series of steps for causal analysis during accident and incident investigation. The main steps are listed below:

  1. Preliminary analysis (causal analysis)
    • Define situational variables (description of the work scenario)
    • List possible incident sequences/scenarios
    • Select key events or sequences to focus on
    • Identify possible causal factors
    • Identify possible controls or systems
  2. Investigate and update causal diagram
  3. Determine pattern of event (see Fifth Discipline ISBN 0385260954)
  4. Identify relevant legislations
  5. Evaluate systemic structure (see Fifth Discipline ISBN 0385260954)
  6. Develop recommendations and implementation plan
  7. Reporting to management and implement recommendations
  8. Finalise and store causal analysis for knowledge management purpose

Propane tank explosion

Thursday, January 31st, 2008

Was reading CSB’s email bulletin on the propane tank explosion at West Virginia (http://www.csb.gov/index.cfm?folder=news_releases&page=news&NEWS_ID=411) and I found this video of an propane tank explosion at Tacoma (don’t it’s the same accident). http://www.break.com/index/tacoma-propane-tank-explosion.html really powerful explosion…