accident investigation: the “3w” process gary d. braman, csp sikorsky aircraft corporation a...
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Accident Investigation:Accident Investigation:The “3W” ProcessThe “3W” Process
Gary D. Braman, CSP Sikorsky Aircraft Corporation
A Presentation to theTennessee Valley Chapter
American Society of Safety EngineersFebruary 19, 2009
Accident Investigation:Accident Investigation:The “3W” ProcessThe “3W” Process
Accident Investigation:Accident Investigation:The “3W” ProcessThe “3W” Process
Accident Investigation:Accident Investigation:The “3W” ProcessThe “3W” Process
Accident Investigation:Accident Investigation:The “3W” ProcessThe “3W” Process
Accident Investigation:Accident Investigation:The “3W” ProcessThe “3W” Process
What happenedWhat happened? ?
Human error, material Human error, material failure/malfunction, or failure/malfunction, or
environmental condition environmental condition that contributed to the that contributed to the
accidentaccident
Accident Investigation:Accident Investigation:The “3W” ProcessThe “3W” Process
Why Did it HappenWhy Did it Happen??
What caused it? What caused it? System inadequacy (root System inadequacy (root
cause) or the why the task cause) or the why the task error occurred .error occurred .
Leader failure.Leader failure.
Training failure.Training failure.
Standards/Procedures failure.Standards/Procedures failure.
Support failure.Support failure.
Individual failure.Individual failure.
Accident Investigation:Accident Investigation:The “3W” ProcessThe “3W” Process
What can be done to What can be done to prevent it from happening prevent it from happening
againagain? ?
The corrective actions that will The corrective actions that will prevent this type of accident from prevent this type of accident from
happening again. happening again.
All corrective actions recommended All corrective actions recommended must be addressed to appropriate must be addressed to appropriate level of management and focus on level of management and focus on
the “why.” the “why.”
The 3W Process can be used to investigate:
Major accidents
Minor accidents
Incidents
Near misses
Accident Investigation:Accident Investigation:The “3W” ProcessThe “3W” Process
“The Bottom Line”
Thoroughly investigating all categories of mishaps,
incidents and near-misses saves lives and
resources
For every major accidents there is an estimated 600 near-
misses
Accident Investigation:Accident Investigation:The “3W” ProcessThe “3W” Process
Accident Investigation:Accident Investigation:The “3W” ProcessThe “3W” Process
Accident Investigation:Accident Investigation:The “3W” ProcessThe “3W” Process
Accident Investigation:Accident Investigation:The “3W” ProcessThe “3W” Process
Accident Investigation:Accident Investigation:The “3W” ProcessThe “3W” Process
Questions???
Accident Investigation:Accident Investigation:The “3W” ProcessThe “3W” Process
Thank You!!!
Accident Investigation:Accident Investigation:The “3W” ProcessThe “3W” Process