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Accident InvestigationPreparation and Preliminary
Examination
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Terminal Learning Objective• Action: Determine the support items
required to conduct an accident investigation
• Condition: Given a simulated accident site and an accident investigation kit
• Standard: Student must choose the appropriate tool for the task and demonstrate correct operation of the equipment
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Risk Assessment• Safety Requirements: None
• Risk assessment Level: Low
• Environmental Considerations: None; however, it is the responsibility of all Soldiers and DA civilians to protect the environment from danger.
• Evaluation: Group practical exercise and questions on the Accident Investigation exam.
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References
• DA Pam 385-40, Army Accident Investigations and Reporting
• Aircraft Accident Investigation, Wood & Sweginnis
• Accident Investigator’s Handbook
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Overview
• Preparation for an Accident Investigation
• Investigator Safety
• Accident Notification Process
• Accident Investigation Kit
• Support Items
• Field Investigation Equipment
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Overview
• The 3W Process
• Preliminary Site Procedures
• Preservation of the Site
• Qualities of An Investigator
• Support Plan
continued
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Prepared For Anything
• Standing List
• Be Prepared
• Deployment Kit
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Investigator Safety
• Physical Fitness
• Immunizations
• Diet/Nutrition
• PPE
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Accident Notification
Before you run…
• Gather your thoughts
• Implement the pre-accident plan
• Gather equipment
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Accident Investigation KitPrimary Kit
• Carrying case for kit contents
• Camera (digital with memory media)
• Tape recorder, batteries, and tape
• Inclinometer/Abney level
• Tape measure (100 foot)
• Optic range finder/distance measuring
• Flashlight (w/ batteries)
DA Pam 385-40, Para. 2-9DA Pam 385-40, Para. 2-9
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Accident Investigation Kit
Primary Kit
• Magnetic compass (lensatic)
• Small magnifying glass
• Pocket/universal multi-tool, with case
• Steel ruler (1 foot) with large index
• Screwdrivers (flat tip and cross tip)
• Pliers and crescent wrench (8 inch)
DA Pam 385-40, Para. 2-9, b (9)-(14)DA Pam 385-40, Para. 2-9, b (9)-(14)
continued
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Investigation Kit References• DA Pam 385-40
• Appropriate report forms:
• AAAR -- DA Form 2397 series
• AGAR -- DA Form 285 series
• Additional references
– Technical manuals
– Field Manuals
– Training Circulars
– Local regulations and SOPs
DA Pam 385-40, Para. 2-9, b (15) - (17)DA Pam 385-40, Para. 2-9, b (15) - (17)
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Support Items
• Batteries
• Office supplies
• Clip board/ notebook
• Templates
• Poncho
• Plastic bags
• Camelback
• Power bar and/or snacks
• First aid kit
• Hat, sun glasses, sun screen, bug repellant
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Cases
Durable, Weatherproof,
Portable or Wheeled
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Angles and Azimuths
Abney Inclinometer
Lensatic Compass
Suunto Tandem
Protractor
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Tools
Screwdriver
ViseGrips Magnifier
Adjustable WrenchFlashlights
Inspection
MirrorMulti-tool
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Retractable Rule
100 Foot Rule
Metal Ruler
Measuring
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Electronics
Range Finder
w/Binocular
Range Finder
w/CompassRange Finder
Only
Digital or Tape Recorder GPS Camera and “Film”
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Personal Survival
Repellant First Aid
FoodSunscreen
Hydration
Protection From Elements
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Investigator Protection
TyvekParticulate
Mask
Eye Protection
Rubber Gloves Leather Gloves
Respirators
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Field Kit
• Bag
• Camera
• Marking tape
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Phase 1: Organization & Preliminary Examination
D+1
Phase 2: Data Collection
Phase 3: Analysis/Deliberations
Phase 4: Complete Field Report
D+2 D+11 D+12
Typically, the investigation will Typically, the investigation will take 14-21 daystake 14-21 days
Staffing
D+13
Outbrief
CAI Time Line CAI Time Line ((by Phaseby Phase))
D+14
DA Pam 385-40, Para. 2-1
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The 3W Process
1. What happened?
• Task (human) error, material failures/malfunctions or environmental condition that contributed to the accident (Tables B-1 thru B-4, DA Pam 385-40).
• Avoid preconceived ideas
• Follow a set pattern (deliberate)
• Be flexible, adjust to situations
DA Pam 385-40, Para. 1- 5DA Pam 385-40, Para. 1- 5
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The 3W Process2. Why Did It Happen?
• What caused it? System inadequacy (root cause) or the why the task error occurred (Table B-5, DA Pam 385-40)
• Leader failure
• Training failure
• Standards/Procedures failure
• Support failure
• Individual failure
DA Pam 385-40, Para. 1- 5DA Pam 385-40, Para. 1- 5
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The 3W Process3. What to do about it?
• The corrective recommendations that will prevent this type of accident from happening again (Table B-6, DA Pam 385-40).
• All corrective actions recommended must be addressed to the appropriate level of command:
• Unit
• Higher Command
• Army level
DA Pam 385-40, Para. 1- 5DA Pam 385-40, Para. 1- 5
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Initial Organization of Board
• Meeting before going to the accident site Members understand:
– Their areas of responsibility
– Initial tasks to be completed
– Data elements required to complete the report
– Preliminary actions taken by unit or installation personnel
DA Pam 385-40, 2-1, b(1)
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Preliminary Accident Site Procedures
Procedures consisting of actions that normally occur according to the unit pre-accident plan
• Unit/installation safety officer takes charge
– After EOD, chemical, fire fighting, rescue, and law enforcement have completed duties
– Fire Chief declares site safe for entry
DA Pam 385-40, Para. 2-2DA Pam 385-40, Para. 2-2
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Preliminary Accident Site Procedures
• First priority: Safety of victims and personnel involved
− Occupants
− Fire/rescue personnel
− Security personnel
− Witnesses
− Bystanders
− InvestigatorsDA Pam 385-40, Para. 2-2, b (1)DA Pam 385-40, Para. 2-2, b (1)
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Preliminary Accident Site Procedures
• Deceased personnel
– Photograph and examination, if possible, before extraction
– Approval required by coroner or medical examiner before moving bodies if off-post
– If coroner performs autopsy, the board president must request a military forensic pathologist be present
DA Pam 385-40, Para. 2-2, b (1) (d)DA Pam 385-40, Para. 2-2, b (1) (d)
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Preliminary Accident Site Procedures
• Securing the Scene
– Rope off accident site
– Post guards
– Establish entry point and pass system
– Ensure protective measures for
• Composites
• Bloodborne pathogens
DA Pam 385-40, Para. 2-2, b(2)DA Pam 385-40, Para. 2-2, b(2)
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Preliminary Accident Site Procedures
• Preservation of the Accident Site
– Safeguard wreckage and evidence from sightseers
– Preserve
• Ground scars
• Vegetation
– Create wreckage distribution diagram
DA Pam 385-40, Para. 2-2, c.DA Pam 385-40, Para. 2-2, c.
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Qualities of an Investigator• An open mind
• Capacity for hard work
• Common Sense
• Integrity
• Keep the faith
• Perseverance
• Technical knowledge
• Tact
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Support Plan
Commanders assigned responsibility for the conduct and support of accident investigations will ensure that a local safety professional is available from the local safety office to assist the accident investigation board.
DA Pam 385-40, Para. 2-1, d.DA Pam 385-40, Para. 2-1, d.
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Support PlanThe duties of the safety representative:
– Provide investigation kit
– Advise board concerning:
• Technical report
• Advice on administrative procedures
– Provide regulatory documents and directives
– Interpret local regulations
– Coordinate work space
DA Pam 385-40, Para. 2-1, d.DA Pam 385-40, Para. 2-1, d.
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Support Plan Commander ensures the board president receives
the following support if necessary:
• Engineer
• Local TASC/PA (Photography)
• PAO
• Hospital commander
• Provost Marshall
• Weather Officer
• Maintenance Support Facility Commander
• Transportation Officer
DA Pam 385-40, Para. 2-1, d.DA Pam 385-40, Para. 2-1, d.
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Support Plan Additional technical assistance:
– Assistance for assets available to local commander
• Metallurgists
• Power plant engineers
• Fuel and oil analysis
• Other
– Assistance outside the local command
• Request through USACR/SC
DA Pam 385-40, Para. 2-1, d.DA Pam 385-40, Para. 2-1, d.
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Support Plan Collateral investigation interface:
• Record of facts for use in litigation, claims, and other administrative and disciplinary actions
• Accident and criminal investigations get priority
• Accident board
– Releases common source information to collateral
– Cannot release content of witness statements, findings, analysis, and recommendations
DA Pam 385-40, Para. 2-1, f.DA Pam 385-40, Para. 2-1, f.
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Support Plan Criminal investigation interface:
– Contact ASAP
– Assumed criminal investigation authority?
– Both CID and accident investigations proceed while determining if criminal intent exists
– Accident investigation board may use any CID information (report, witness statements, photos, etc.)
– Factual data release to CID only
DA Pam 385-40, Para. 2-1, g.DA Pam 385-40, Para. 2-1, g.
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Support Plan
Minority Report:
• Official report is signed by the board president
• Disagreeing board members will submit minority report
• Minimum requirements for report
– Analysis paragraph explaining disagreement
– Signature block of minority members
DA Pam 385-40, Para. 2-1, h.DA Pam 385-40, Para. 2-1, h.
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Investigation Plan• Phase 1
Organization and Preliminary Examination
• Phase 2
Data Collection
• Phase 3
Analysis of the Data
• Phase 4
Completing the Technical Report
DA Pam 385-40, Para. 2-1DA Pam 385-40, Para. 2-1
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SUMMARY