The standard starting point to commence working towards both active and latent cause analysis failings within an investigation Is to first and foremost gather the following 5 items, i.e. before posting on this forum.
1. Simple Statement.
2. Simple (hand drawn) Schematic.
3. (hand drawn) Relationships
4. Short Summary sequence of events and
5. Oddities (these always exist)
(Please refer to accident case study example file as attached)
Construct one or two paragraphs. Intent is to be brief, to the point. Should be written by one person to summarize ESSENTIALS so that evidence freezing can begin immediately.
Hint: The accident / incident descript statement should read like a paragraph in the initial event statement developed.
1. Who (did this happen tool)?
2. What (was the actual / potential consequence)?
3. Where (did this happen)?
4. When (did this happen)?
Make a hand drawn schematic of the system(s)s, equipment, or components involved. – Not an engineering drawing pulled from the files. ‘HAND DRAWN’ showing the sequence of the state of things at the time of the accidents, incident event.
o What is known?
o What is unknown?
o Know what is unknown?
Hint: Take time to understand the
schematic before moving on to begin any evidence gathering process, that later
follows. Insert labels such that a reader can understand the reminder of the 5
item’s document. Make sure all items referred to in the other portions of the
document are included. KEEP IT SIMPLE!
Make another HAND-DRAWN schematic, this time showing the relationships of the system, equipment or component parts involved in the accident / incidence event to the rest of the facilities.
Make a summary of the sequence of event leading up to the accident / incident event. Written by ONE person (with approximately 5 bullet items).
Hint; Not intended to be a detailed sequence, i.e. only 5-8 bullet points
List what was odd about this event.