1. No category

2013-09-20
Use of different accident investigation
methods
Presentation at Granskningskonferansen 2013
Stavanger 2013-09-17
Mattias Strömgren,
MSB and Karlstad University
The process of accident investigation
Preperdness
for accident
investigation
Initial accident
information
Planning of
investigation
Data collection
Accident analysis
Development of safety
improvement
Conclusions and
reporting
Decisions
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2013-09-20
The purpose of accident investigation
• Identify and describe the true course of events (what,
where, when)
• Identify the direct and root causes / contributing factors
(why)
• Identify measures to prevent future (comparable)
accidents (learning)
• Investigate and evaluate the basis for potential criminal
prosecution (blame)
• Evaluate the question of guilt in order to assess the
liability for compensation (pay)
(Sklet, S. 2002)
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Data collection
•
•
•
•
•
•
•
•
•
Examine accident site
Interviews
Technical investigation
Document examination
Data log (recorders, etc.)
Verbal communications
Expert judgments
Media reporting
Weather conditions
Photo: Helen Fagerlind
Swedish Civil Contingencies Agency
Scource: The Swedish Accident Investigation Authority
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2013-09-20
Accident analysis
Common questions
• What happened?
• How did it happened?
• When did it happened?
• Where did it happened?
• Why did it happened?
• How was circumstances around?
• What could had prevented the event? Mitigated
consequences?
• Aspects on the rescue operation?
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”What-You-Look-For-Is-What-You-Find*”
• Underlying accident models influence
investigation
• You don’t find causes – You construct them**
• Accident models emphasis different aspects on
the event, causes and contributing factors
• Accident models are closely connected to
investigation methods (data collection and
analysis)
– Sequential models
– Epidemiological models
– Systemic models
(* Lundberg, Rollenhagen, Hollnagel 2009
** Dekker 2006)
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2013-09-20
Underlying theories – accident models
Parliament
Government
Decisions
Laws
Agencies
Decisions
Regulations
Company
C.E.O
Decisions
Company
policy
Decisions
Planning
Company
Operative
management
Company
staff
Decisions
Action
Physical
process
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Acciendent models - methods
Risk analysis
method
Accident
model
• Safety
measures
• Control
systems
• Barriers
Accident
investigation
method
• Attitudes
• Behaivors
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2013-09-20
Accident investigation
methods ?
•
•
•
•
•
•
•
Eye opener, mind stretcher
Systemized procedures – quality control
Help seeking and sort data and answers
Makes a picture (representation) of accident
Ease communication about accident
Different methods gives different results
Purposes and outlines for investigation work
influence choice of methods
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Some examples of methods
Händelseutredning
Avvikelseutredning
AcciMap
Händelseträdsanalys
SYSTEMNIVÅ
Orsak /
förutsättning
Orsak /
förutsättning
Orsak /
förutsättning
Orsak /
förutsättning
Orsak /
förutsättning
Orsak /
förutsättning
Orsak /
förutsättning
Orsak /
förutsättning
Lagstiftande nivå
Avvikelse
Risk Bedömning
Problem
Åtgärdsförslag
Kommentar
Avvikelse 1
Avvikelse 2
S2, P3
M1
Åtgärd 1
Åtgärd 2, 3
Avvikelse 3
Avvikelse 4
S1, M2
P2
Åtgärd 4
Åtgärd 5, 6,
7
Taktisk nivå
Åtgärd 8
Operativ nivå
Avvikelse 5
H2, S1
Förutsättning
som ej utreds
vidare
Föreskrivande nivå
Beslut
Händelse 2
Händelse 3
Barriär b
Nej
Nej
Funktion
Konsekvens
Kritisk
händelse
Funktion
Konsekvens
T
JA
M
NEJ
T
D
O
NEJ
IKON
FENOTYP
– dysfunktionellt
beteende
C1
Aktör
B1
A1
IKON
Händelse
Aktör
Olycka
C3
Aktör
Händelse
IKON
AEB
SCAT
MÄNNISKA
Otillräcklig
styrning
Grundläggande
orsaker
Direkta
orsaker
Olyckssituation
Jämför
Felhändelse
ELLER
OCH
Identifiera
skillnader
Analysera
effekter
Olycksfri
situation
Program
Personliga
faktorer
Arbetsfaktorer
Oönskad
händelse
Resursförlust
Fysisk
belastning
Människa
Handling
Rutiner
Efterlevnad
Resultat
Händelse
3
IKON
Change analysis
Topphändelse
2
Händelse
1
B1
IKON
Felträdsanalys
IKON
STEP
DREAM
C2
Felhändelse
Konsekvens K5
IKON
TapRoot
I texten /
Kommentarer
OCH
Konsekvens K4
Nej
Förutsättning
som ej utreds
vidare
Konsekvens
GENOTYPER
– möjliga orsaker
Säkerhetsfunktion 4
Ja
Konsekvens
Nivå 1
Säkerhetsfunktion 3
Konsekvens K3
Ja
Aktivitet
IKON
Säkerhetsfunktion 2
Konsekvens K2
Ja
7
Funktion
Barriär c Barriär d
Säkerhetsfunktion 1
Vägval D
Konsekvens K1
Nej
Funktion
Order
Händelse 4
Typ* Sub* Fungerade
Vägval C
Ja
Starthändelse
Funktion
Takt. plan
Aktivitet
Säkerhetsfunktionsanalys
Säkerhetsfunktion
Vägval B
Beslut
Strat. plan
Fysisk nivå
Barriär a
Vägval A
Föreskrift
Strategisk nivå
Aktivitet
Händelse 1
3
Tillstånd
Maskin
Kemisk
påverkan
Psykisk
påverkan
TEKNIK
Felhandlande 1
Felhändelse 1
Felhandlande 2
Felhändelse 2
Felhandlande 3
Olycka
Material
Miljö
Produktion
Felhändelse
Felhändelse
Felhändelse
Felhändelse
IKON
Barriärfunktion
IKON
IKON
IKON
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2013-09-20
Some examples of methods
Investigation method
Short description
Reference
AcciMap
The accident is analyzed with reference to different hierarchical levels of
society. Identification and analysis of socio-technical context, decision
and information flows between different actors.
(Rasmussen and
Svedung, 2007;
Svedung and
Rasmussen, 2002)
AEB (Accident
Evolution and Barrier
Function Method)
The method highlights the interaction between the human and the
technical sub-systems, as well as barrier functions involved. Technical
and human failures are modeled.
(Svenson, 1991,
2000, 2001)
Deviation Analysis
The method identifies and assesses deviations that occurred before,
during and after the accident, and help prioritizing proposals for
correction.
(Harms-Ringdahl,
2001, 2010; Kjellén
and Larsson, 1981)
DREAM (Driving
Reliability and Error
Analysis Method)
DREAM is adapted for road traffic accidents and includes analysis of
cognitive and perceptual processes, as well as the interaction between
human actions and technological systems. DREAM is based on a method
called CREAM (Cognitive Reliability and Error Analysis Method).
(Ljung et al., 2004;
Wallén Warner et al.,
2008)
Fault tree analysis
Safety problems are analyzed based on logical combinations of necessary
or alternative/possible causes.
(Harms-Ringdahl,
2001; Henley and
Kumamoto, 1981)
MTO event
investigation
The method investigates sub-events sequentially, and analyses the direct (Rollenhagen, 2003,
and underlying causes and safety barriers. Organizational factors are also 2011), also available
in (Sklet, 2002)
considered.
SCAT (Systemic Cause Based on questionnaires, accidents causes are identified and related to
shortcomings in the work environment, performance factors and
Analysis Technique)
(Bird and Germain,
1985)
management systems.
SFA (Safety Function
Analysis)
Analysis of various forms of technical, organizational and administrative
systems (safety functions), aimed to control and reduce risks.
STEP (Sequential
Timed Events
Plotting)
Analysis of the accident sequence by the identification of actors and sub- (Hendrick and
Benner, 1987)
events in time order, plus their interactions as well as safety problems.
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(Harms-Ringdahl,
2001, 2009)
MTO event investigation
The method investigates sub-events sequentially, and analyses the direct and
underlying causes and safety barriers. Organizational factors are also considered.
Why (Organisation
/ management
level)
Why
(Explanations)
What
(Timeline)
Cause /
preconditions
Cause /
preconditions
Cause /
preconditions
Cause /
preconditions
Event 1
Cause /
preconditions
Cause /
preconditions
Event 2
Barrier a
Event 3
Barrier b
Cause /
preconditions
Cause /
preconditions
Event 4
Barrier c Barrier d
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2013-09-20
MTO event investigation:
Fish boat sank
Water gets
into the
vessel
J trapped in
wheelhouse
The vessel
sank
EPIRB
SIGNAL 15:35
J reported
overdue
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STEP (Sequential Timed Events Plotting)
Analysis of the accident sequence by the identification of actors and sub-events
in time order, plus their interactions as well as safety problems.
to
Time
Actors
Actor 1
Event
Event
1
5
Actor 2
Event
Event
4
Actor 3
Event
2
Actor x
3
Event
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2013-09-20
STEP:
Traffic accident
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AcciMap
The accident is analyzed with reference to different hierarchical levels of
society. Identification and analysis of socio-technical context, decision and
information flows between different actors.
Figure: Inge Svedung, Karlstads universitet
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2013-09-20
SYSTEM LEVEL
Market
pressure
6. International co-ordination
& directive
5. Government policy &
legislation
Large order
of K34
HQ Strategic
planning of
production sites
Accimap:
Accident with release of toxic gas
OSHA
inspections
HQ Decision
to increase
production
Legislation
don’t require
info to public
or authorities
7
Whistleblowers
neglected
4. Central & regional
authorities
Threat of
shutting
down plant
3. Local authorities, strategic
management level
2. Technical & operational
management level
Postponed
maintenance
unit 7
3
Decision to
put unit 7 in
operation
up unit 7
Water is
found in
701
Water in
701 is
removed
2
No
additional
personal
1
Inexperienced
personal in
critical positions
Runaway
reaction
in 701
Batch in 701
is dumped
into 702
Level gauge in
701 shows more
then expected
Leakage
into 702
Design of
process
Routines of
instrument
shop
Unit 7 put
in operation
Leakage into 701
Rain
Policy for
handling
spare parts
Production
planning
Short-cuts in
starting-up
procedures
on unit 7
Water in 701
0. The physical system ,
the environment
Rain
Timepressure
Planning of
maintenance
1. Operational level, course
Preparation
of starting
of events
Leakage
into 701
Costcutting
Routines for
deviation
analysis
4
Medical
disaster
planning
Evacuation
planning
General
routines for
emergencies
8
Level
gauge in
702 is
missing
Water in 702
Land use
planning
Location of
residential
area close
to plant
Manny people
close to plant
5
Runaway
reaction
in 702
Level gauge
in 702 is
regarded as
broken
Public
concerned
about risks
Evacuation
plan
outdated
Missing
access to
backup
level gauge
Level gauge
in 702 transferred to 701
Benefits for
community
No adequate
info about
risks
Rescue
service
planning
Legislation /
policy
Overpressure
in 702
6
Explosion
in tank
702
5
Uncontrolled
release of toxic
gas
460 people
died
Wind direction
towards
Swedish Civil Contingenciesresidential
Agencyarea
Accident with leakage of diesel on
water protection area
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2013-09-20
AcciMap
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AcciMap
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2013-09-20
Deviation Analysis
The method identifies and assesses deviations that occurred before, during
and after the accident, and help prioritizing proposals for correction.
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Deviation Analysis:
Fire in a house
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2013-09-20
Research project:
A process-oriented evaluation of nine accident
investigation methods
• The aim was to evaluate and categorize nine established
accident investigation methods empirically with regard to
their ability to support a generic investigation process
• Data collected from participants in eight courses in
Advanced Accident Investigation Methodology held annually
at Karlstad University in Sweden
• Article:
Strömgren, M., Bergqvist, A., Andersson, R., & HarmsRingdahl, L. (2013). "A process-oriented evaluation of nine
accident investigation methods." Licentiate thesis,
Strömgren, Karlstad University 2013:24
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Research method
• Data and experiance from the
course Advanced accident
investigation methodology, 7,5
ECTS
• 8 year and 172 course
participants
• 114 method test applied at 36
real accident/incident
• Evaluation of 9 investigation
methods:
1.
2.
3.
Group evaluation
Classroom evaluation
Compiling and analysis by
course leader
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2013-09-20
Course participants – from many
industries
Industries
Railway
Occupational health & safety
Process industry
Rescue services
Power industry
Health care
Petroleum industry
National defense
Shipping port
University
Mining industry
Police
Nuclear industry
Shipping
Aviation
Road traffic
Photo: Gunnar Enghamre och Maria Gradin, Tekniska roteln, Polisen Västerås
Swedish Civil Contingencies Agency
A generic model of the accident investigation process
Parameters for evaluation
Support in Description /
method
comments
0 No support The phase is not
mentioned or regarded.
1 Some
The phase is mentioned
support
and generally
discussed.
2 Advice
The phase is described
and contains
instructions and/or
categorizations.
3 Extensive
The phase is a distinct
advice
activity in the method
and is clearly described.
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2013-09-20
Result
Criteria
AcciMap
P1 Planning
of
investigation
C
P2a Basic
data
collection
1
P2b
Supplementar
y data
collection
1
P3a Data
selection &
sorting
1 (2)
P3b
Aggregating
& synthesis
2 (1)
P3c
Interpretatio
n & reflection
1
P4 Evaluation
0
P5 Develop
safety
improvments
0
P6 Final
conclusions &
reporting
1
AEB
Fault
Deviation DREAM
Tree
MTO event
Analysis (CREAM) Analysis investigation
SCAT
SFA
STEP
A
A
A
B
B
A
A
A
0
1 (2)
1
0
0
2
1
3
0
2
1
0
1
0
1
2
2 (3)
3
3
1
1 (2)
2
3
3
2
2
3
2
2
2
2
3
1
1
1
3
0
0
2
1
0
0 (1)
0
0
0
3
3 (2)
1
2 (3)
3
0
0
1
1
2 (3)
2
1
1
1
0
1
0 (1)
1 (2)
2 (1)
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Result
Criteria
AcciMap
P1 Planning
of
investigation
C
P2a Basic
data
collection
1
P2b
Supplementar
y data
collection
1
P3a Data
selection &
sorting
1 (2)
P3b
Aggregating
& synthesis
2 (1)
P3c
Interpretatio
n & reflection
1
P4 Evaluation
0
P5 Develop
safety
improvments
0
P6 Final
conclusions &
reporting
1
AEB
Fault
Deviation DREAM
Tree
MTO event
Analysis (CREAM) Analysis investigation
SCAT
SFA
STEP
A
A
A
B
B
A
A
A
0
1 (2)
1
0
0
2
1
3
0
2
1
0
1
0
1
2
2 (3)
3
3
1
1 (2)
2
3
3
2
2
3
2
2
2
2
3
1
1
1
3
0
0
2
1
0
0 (1)
0
0
0
3
3 (2)
1
2 (3)
3
0
0
1
1
2 (3)
2
1
1
1
0
1
0 (1)
1 (2)
2 (1)
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2013-09-20
Additional features
Criteria
Training
needs
Reliability
Output
format
AcciMap
AEB
4
1
2
3
A3 (A1)
C
A1 + C
Deviation DREAM
Analysis (CREAM)
Fault
Tree
Analysis
MTO event
investigation
SCAT
SFA
STEP
2
3 (2)
3
4
4
2 (3)
3 (2)
3 (2)
2
3 (2)
2
2 (3)
2
3 (2)
B
A2
A2
A1 + A3
C (A2)
B (A3)
A1 +
A3
1.
2.
3.
4.
5.
No training, just a short introduction
Practical training, a few hours.
Education and training needed for some days.
Some weeks of training and practice.
Expert-knowledge with extensive experience.
1.
2.
3.
4.
5.
Varies greatly
Varies somewhat
Quite independent
Reproducible
Highly reproducible
A. Graphic representation
1. Accident evolution process
(sequence)
2. Tree-format
3. Web connecting elements
B. Table (≥ two parameters)
C. List
D. Free text
E. Other
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Triangulation
• Data triangulation
• Investigator triangulation
• Method triangulation
– Gives new insight
– Gives different perspectives/results
– Biases between methods
– Start with sequence based method
– Complement with systemic based method
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Conclusion
• None of the compared methods provides full support
for all phases of the accident investigation process
• Deviation Analysis and STEP gives the best support for the investigation
process
• Only STEP, Deviation Analysis and SCAT provides good support for data
collection
• Most methods gives good support for analysis – rename:
Accident analysis methods
• Different demands of education/training – easy/difficult
• Different analysis result
• Different output format
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Some quality parameters
• Purpose of investigation
• Who is the investigator(s)?
(investigators knowledge, experience, background)
• Who is the commissioning body?
• Bias / objectiveness
• Data sources / data collection
• Type of system / accident model used
• Use of accident analysis method(s)
• Logic, causality, transparence, confidence
• Safety improvements
• Learning strategies
• Dissemination of results
Swedish Civil Contingencies Agency
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2013-09-20
Chain of quality in accident
investigation
Purpose
Data
Analysis
Conclusions
Recommendations
Swedish Civil Contingencies Agency
Thanks for your attention
Mattias Strömgren
[email protected]
+46102405678
Swedish Civil Contingencies Agency
17