A 5-step approach to accident investigations
One question that is asked regularly is, “Do carriers have to investigate crashes?”
The short answer is no, they don’t. However, to prevent future crashes and have an effective safety management control system when it comes to preventing crashes (see 385.5), crashes should be investigated.
Here is an example: Recently, federal crash investigators at the National Transportation Safety Board concluded that a truck driver's improper licensing and lack of knowledge about vehicle operation led to a fatal crash in Illinois. Had the driver's employer conducted post-crash investigations on previous crashes, they might have learned of the possibility of such violations and taken steps to improve long before this crash occurred.
Process
Investigating a crash is much like investigating anything else. Know and use a structured and scientific method. This is important to uncover the facts of the situation and make reasonable conclusions. Here is a common approach to investigating a crash:
- Gather data: This includes all information that can be gathered including, but not limited to:
- The complete police accident report;
- The insurance company’s report;
- Photos and videos of the scene (including vehicles);
- Videos from dash cameras and fixed facilities (such as security cameras);
- Scene diagrams based on on-scene evidence indicating direction of travel, lane position, impact point, visibility, etc.;
- Witness statements;
- The driver’s logs, supporting documents, and other electronic records leading up to the crash;
- A download of the engine control module (ECM);
- The driver’s statements and reports;
- The driver qualification file and training records;
- The vehicle maintenance file; and
- Any post-crash vehicle inspection records.
- Vet and rank the data: Verify that all data is correct. If there is conflicting data, such as a driver’s statement not matching the vehicle’s ECM data, objectively decide which is correct (or more correct).
- Reconstruct the crash: Using the vetted and ranked data (and nothing else — no opinions allowed!), put together the crash sequence and driver actions, preferably starting several seconds to 15 seconds before the crash.
- Determine the root cause and causal factors and look for preventability: This can be done using the Fishbone, 5 Whys, or another root-cause approach. As the crash is reconstructed, consider the causes, look for the chain of events which, if it had been broken, would have prevented the crash. During this analysis, determine if the driver or company could have taken one or more actions to prevent the crash (i.e., break the chain). Examples of such actions include making sure the driver had the right skills and knowledge, or properly equipping and maintaining the vehicle.
- Take action: If the investigation found preventable actions, address them. This can include counseling, retraining, and/or terminating the driver, and making any systemic improvements to company policies, procedures, practices, and training to prevent the crash from happening again.
Step five is critical; the whole reason to investigate a crash is to use the results to prevent the next one.
A word of warning
If the crash was serious (injuries, fatality, etc.), and litigation is a possibility, a carrier may NOT want to do an internal investigation and instead leave it to the lawyers and their experts. This way, the attorney can coordinate the investigation and protect some aspects of it from discovery. This will also prevent the carrier from confusing the fault decisions of others.
Get training
Effectively investigating crashes requires specific knowledge, skills, and reasoning. A safety professional who has not been formally trained on how to do it, should consider taking a course on accident investigation.
Key to remember: A five-step approach to crash investigation can help identify why a crash occurred and the actions needed to prevent future crashes.