ASP Incident Investigation and Analysis 2 — Questions and Answers
Question 1: What is the primary goal of an incident investigation?
- To assign blame to the responsible employee
- To identify root causes and contributing factors to prevent recurrence (Correct answer)
- To calculate property damage costs
- To satisfy insurance documentation
Correct answer: To identify root causes and contributing factors to prevent recurrence
The primary goal is to identify root causes and contributing factors so corrective actions can prevent similar incidents.
The investigation process involves gathering evidence, analyzing events, identifying immediate and underlying root causes, developing corrective actions, and tracking implementation.
Question 2: What is the '5 Whys' technique in root cause analysis?
- Asking five different employees what happened
- Repeatedly asking 'why' about each answer to drill down from symptoms to root causes (Correct answer)
- Investigating five incidents simultaneously
- Reviewing five years of history
Correct answer: Repeatedly asking 'why' about each answer to drill down from symptoms to root causes
The 5 Whys involves repeatedly asking 'why' each cause occurred until the fundamental root cause is uncovered.
Developed by Sakichi Toyoda for Toyota. Starting with the problem, ask 'why' for each answer. The technique is simple but may oversimplify complex incidents; best combined with other methods.
Question 3: What type of evidence should be collected first at an incident scene?
- Written witness statements
- Perishable or transient evidence that may change or disappear (Correct answer)
- Equipment maintenance records
- Company policy documents
Correct answer: Perishable or transient evidence that may change or disappear
Perishable evidence such as weather conditions, fluid levels, and temperature readings should be collected first.
Transient evidence includes weather, lighting, temperatures, positions of controls, fluid conditions, odors, and surface conditions. Photographs and video should be taken immediately before anything is moved.
Question 4: What is a fault tree analysis used for in incident investigation?
- Tracking employee attendance
- Working backward from an undesired event to identify all possible combinations of failures and conditions that could cause it (Correct answer)
- Calculating financial cost of faults
- Ranking employees by their faults
Correct answer: Working backward from an undesired event to identify all possible combinations of failures and conditions that could cause it
Fault tree analysis is a deductive technique that works backward from an undesired event to identify all possible failure combinations.
FTA uses Boolean logic gates. AND gates indicate multiple conditions must exist simultaneously. OR gates indicate any single condition is sufficient. It produces a visual logic diagram showing all causal pathways.
Question 5: Why should witness interviews be conducted separately during an incident investigation?
- To save time
- To prevent witnesses from influencing each other's recollections and to get independent accounts (Correct answer)
- To reduce the total number of witnesses needed
- To make witnesses more comfortable refusing to answer
Correct answer: To prevent witnesses from influencing each other's recollections and to get independent accounts
Separate interviews prevent witnesses from unconsciously influencing each other's memories and ensure independent accounts.
Memory contamination through social influence is well-documented. Best practices include interviewing as soon as possible, separately, using open-ended questions first, and avoiding leading questions.
Question 6: What is the Swiss Cheese Model of accident causation?
- A food safety inspection model
- A model showing that accidents occur when holes in multiple defensive layers align, allowing hazards to pass through all barriers (Correct answer)
- A method for rating cheese factory safety
- A technique for organizing incident reports
Correct answer: A model showing that accidents occur when holes in multiple defensive layers align, allowing hazards to pass through all barriers
James Reason's model illustrates that accidents occur when latent failures in multiple defensive layers momentarily align.
Holes are created by active failures (front-line errors) and latent conditions (organizational factors like poor design, inadequate training). An accident occurs when holes in all layers momentarily align.
ASP Incident Investigation and Analysis 2
What is the primary goal of an incident investigation?