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SMS Operation 107 Table 22. (Continued). SAFETY REPORT PROCESSING FORM (To be completed by SMS Manager) Report Number: Assessed Level of Risk: Date report was received: Referred to: - Appropriate Dept Manager: Yes No, Name/Dept............................ - Safety Committee: Yes No, Name/Organization..................... Entered into Safety Risk Database: Yes No If yes, specify the date. Treatment actions required: Person responsible: Completion date estimated: Feedback: Is reporter known? Yes, advised of outcome on: Date: No, event and action communicated on: Date: Through: Safety bulletin Safety meeting Ramp Safety Committee minutes Other Safety event (describe): Person completing form: ________________________ Signature: Date: __________ Manager/Supervisor: ________________________ Signature: Date: __________ The Freedom of Information Act (FOIA) is applicable to information controlled by the United States government. Each state has its own open records legislation that governs documents at the state and local (cities, counties, school districts) levels. Such legislation may be applicable to your airport. In this case, you must include a note in your Confidentiality Commitment stating that the airport may have a legal obligation to provide all information that is available, including the reporter's identity, if this information is requested and it is available in the airport's records. 6.5 Accident and Incident Investigation Accident investigation is a key component of any SMS. Thousands of accidents occur each day in the United States, some of which could be prevented by identifying the underlying causes of the accident and implementing appropriate corrective actions(34). An accident investigation

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108 Safety Management Systems for Airports program is a safety management tool used to identify the contributing factors and causes of an accident in order to eliminate or mitigate these factors and ensure that similar accidents are not repeated. A qualified investigator is a person that has received training on how to conduct investigations and determine root causes of incidents and accidents. When an accident or serious incident occurs, qualified investigators should be available to conduct the investigation with the follow- ing purposes: Improve understanding of the events leading up to the accident/incident Identify root causes and assess actual hazards Provide recommendations to mitigate risks Communicate lessons learned from the investigation In many instances, the investigation of minor incidents, such as near misses at the ramp, may yield evidence of systemic hazards. For maximum effectiveness, the investigation should focus on determining root causes rather than identifying persons to discipline. The causes of an accident/incident can often be found by asking Who + What + Where + When + How + Why for each key event in the accident/incident until you know why the accident happened. Separate facts from theory and opinion As much as possible, look for underlying causes--avoid jumping to conclusions. Analyze the factors surrounding the accident. It will be necessary to provide appropriate training on topics such as human factors, investi- gation procedures, or interview techniques to some of the appointed personnel. However, you do not need to provide this training to all staff within the organization; you might want to focus on training lead investigators first, for example. Section 6.6 provides additional information on internal safety investigations. Fortunately, since accidents in the aviation industry are rare, you can get a great deal of knowledge and experience by obtaining reports of significant events from external organizations(35), such as regional or international accident or incident reports (e.g., National Transportation Safety Board [NTSB], ICAO, Transportation Safety Board of Canada, UK Air Accidents Investigation Branch). Accident Causes An accident is defined as an unplanned, undesired event that affects the completion of a task. At its lowest level, an accident occurs when a person or an object is exposed to an unsafe level of energy or hazardous material. There are many forms of harmful energy, including acoustic, chemical, electrical, kinetic (impact), mechanical, potential (stored), radiant, and thermal. Acci-

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SMS Operation 109 dents are complex, sometimes involving 10 or more events that can be considered contributing factors. Most accidents have three different cause levels: root, indirect, and direct. The direct cause of the accident would be the energy or hazardous material. The direct cause usually is attributable to unsafe conditions and/or unsafe actions. The unsafe conditions and actions are considered to be indirect causes or symptoms. The indirect causes are typically a result of root causes, which may include an inappropriate procedure for the work or task, adverse environmental factors, personal judgment, and/or poor management decisions. The relation- ship between root, indirect, and direct causes is shown in Figure 15. Most accidents are preventable by simply eliminating one or more of the causes. Proper acci- dent investigations are crucial for determining what happened and how and why it happened. The goal of accident investigation and reporting is to minimize the chance or reoccurrence and in turn to prevent more severe accidents in the future. Types of Events All incidents have the potential to become injury-related accidents and should be investigated. The following terms explain the different types of events that should be investigated to deter- mine the incident's contributing factors: Accident--An accident is an undesired event that results in personal injury or property damage. Incident--An incident is an unplanned, undesired event that adversely affects completion of a task. Near Miss--Near misses describe incidents where no property was damaged and no personal injury was sustained, but given a slight shift in time or position, damage and/or injury easily could have occurred. Accident and incident reports help identify hazards and other contributing factors that may have been overlooked or slipped through the system. They also identify hazards that have the potential to become serious accidents. Management Safety Policy & Decisions, ROOT Personal Factors, Standard Procedure, CAUSES Environmental Factors INDIRECT Unsafe Act Unsafe Condition CAUSES (SYMPTOMS) Unplanned Release of Energy DIRECT and/or CAUSES Hazardous Material ACCIDENT Personal Injury Property Damage Figure 15. Accident causes.

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110 Safety Management Systems for Airports Investigation and analysis follow reporting, hazard identification, or high risk concern. Usu- ally the investigation is conducted by a team/person with experience in the area of concern. Investigation Analysis Techniques There are three techniques commonly used to help understand the underlying causes of inci- dents: the Causation Model, the Fishbone Analysis, and the "5 Whys." Causation Model The basic causes of incidents can be grouped into the five categories shown in Figure 16: task, Environment materials, environment, personnel, and management. All possible causes in each of the cate- gories should be investigated when using this technique. Management Personnel Task. Looking at the causes associated with a task involves exploring the procedure that was being followed when the accident or incident took place. Questions such as "Is the work proce- Task Materials dure safe?" and "Were the tools and materials used appropriate for the existing procedure?" should be asked and the answers documented. Figure 16. Causation Materials. The materials used should be investigated to determine if any possible causes or model. contributing factors can be associated with materials and/or equipment. Questions about equip- ment failure, possible failure mechanism, design, maintenance, hazardous materials, and so on should be asked, and answers should be documented. Environment. Environmental conditions have been known to contribute to unsafe condi- tions and are often a contributing factor in an accident. The actual conditions at the time of the accident and any sudden changes in the environment that could have occurred near the time of the accident should be the focus of the investigation. Personnel. The condition of the personnel (both mental and physical) must be considered as part of this analysis. Again, the objective is not to place blame on an individual, but rather it is to get to the root of the problem and all possible angles should be explored. Questions about employee training, frequency of the work, employee health status (both physical and mental), and so on should be asked. Management. Management personnel and safety policies should be considered during an accident investigation. Ultimately, managers are decision makers and they have a legal respon- sibility to promote safety in the workplace. Some of the direct and indirect causes of an accident are due to failures within a management system. Questions concerning safety policy and proce- dures, inspection schedules, employee supervision and training should be addressed. The causation model is a good tool for determining the causes associated with a specific acci- dent or incident. It is important to note that, when using this model, each time a question reveals an unsafe condition that particular question should be followed up by another question that addresses why the unsafe condition was allowed to exist. Fishbone Analysis This analysis is used in more complex investigations and is particularly useful when many experts are gathered. Typically, each will have his or her own particular expertise and concerns, and the fishbone analysis focuses all participants in the investigation to defined aspects of the operation. An example outline of the technique is shown in Figure 17. The group will include the elements determined from the brainstorm session. In this example, all participants are asked to focus on issues related to defined topics--equip- ment, people, materials, and programs/procedures. Each is discussed in turn, and concerns for

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SMS Operation 111 Equipment People Operational constraint No supervision Monitor failure No training experience Undesirable Effect Under-engineered Lack of commitment Responsibility unclear Off specification Not addressed in procedure Degradation No management system Below specification No policy Lack of maintenance Not covered in maintenance program Program Materials Procedures Figure 17. Fishbone investigation process. each are written on the diagram. Other defined topics may be added at the discretion of the investigating team. At the end of the analysis, the resultant fishbone will look somewhat like the example shown. The concerns identified are then investigated in detail to get to the root causes of the issue. It can be seen clearly that this technique will allow for multiple root causes, ranging from mechan- ical to human and organizational factors. "5 Whys" The following is a simple example of the questioning technique used in the "5 Whys." In this example, depicted in Figure 18, a driver that was hired by a contractor to conduct a construction job on the airside failed to follow the directions from the escort vehicle. The incident resulted in a runway incursion because the driver was not able to speak or understand English; therefore, Runway incursion caused by Driver did not by construction follow escort truck vehicle Driver did not caused by Driver did not follow escort follow airside vehicle rules Driver did not caused by Driver did not follow airside know about the rules airside rules Driver did not caused by Driver did not know about the understand airside rules training provided Driver did not caused by Driver does not understand understand training provided English Figure 18. "5 Whys" investigation process.

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112 Safety Management Systems for Airports the training provided was ineffective. The escort person was not aware of that. The important point is that the investigation discusses issues that would preclude repetition of the problem. Typically, once the issues in the fishbone have been identified, the "5 Whys" technique is applied to each factor in an attempt to find the root causes of each. These techniques allow a skilled team to focus on different aspects of an issue so that all the underlying causes can be addressed. It ensures that no one person is able to dominate the discussion with preconceived ideas, and it also allows both hard engineering issues and human factors issues to be drawn out equally in discussions. It is not normal for people to want to make mistakes, and so these techniques try to ask why people found themselves in the position to make the error in the first place. Getting the Facts The goal of conducting an accident or incident investigation is to gather information that can be analyzed that will lead to the improvement of the airport safety policy and reduce the num- ber of accidents that occur. The following four steps are necessary for creating such a system: 1. Gather Information 2. Analyze Information 3. Draw Conclusions 4. Make Recommendations It is important to gather information from all available sources, which may include, but are not limited to the following: Physical Evidence--Physical evidence is defined as "tangible evidence" (e.g., aircraft damage, picture, document, or visible injury) that is in some way related to the accident/incident that gave rise to the case. Examples include the equipment or materials left at the scene of the acci- dent, the position of injured persons or other objects, the weather conditions, and documen- tation of the involved persons or conditions. All physical evidence should be examined and documented. Eyewitness Reports and Interviews--It is important to gather information from any eyewit- ness reports and, if possible, conduct interviews with all parties involved. Interviews should be conducted from a "fact finding" rather than a "fault finding" perspective. Background Information--All policies, procedures, inspection reports, maintenance reports, and other relevant documents should be considered, and appropriate information should be acquired as part of the investigation. Once all of the information is collected and one of the analysis techniques above is used, the team of investigators should work to draw conclusions. When drawing conclusions, it is impor- tant to answer "why" the accident occurred. It is also important to support and document the root causes with evidence and reasoning. Drawing conclusions based on the gathered information may lead to gaps in the original analysis. If gaps are discovered, the existing information should be re-examined. Sometimes, additional information may need to be gathered to bridge these gaps. The final step is to draft written recommendations for corrective actions to take, and if rele- vant, to improve safety policies and procedures. This step is extremely important to reduce and prevent accidents of a similar nature from occurring in the future. The written recommenda- tions should be as specific as possible and address all root causes and contributing factors. Man- agement should address all recommendations from accident and incident reports by updating safety policy and procedures if necessary.