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