Improving the Quality of Accident Investigation
Authors
Dane M. Mellan, Mason Ruffing, Victor Y. Zeng
Sponsor
National Transportation Safety Board
Advisors
Constance Clark, David DiBiasio, Natalie A. Mello
Term
October – December 2009
Project Outcomes
Abstract
The NTSB Office of Marine Safety (OMS) conducts accident investigations to prevent the reoccurrence of accidents. We compared the OMS and other agencies’ investigations through interviews of experienced investigators and analyses of accident investigation reports. We found inconsistency in definitions and methods used for causal analysis amongst OMS investigators resulted in an increase of report production time. We made recommendations to adopt the IMO causal factors definition as probable cause definition in conjunction with E&CF analysis to improve the quality of OMS’ investigations by increasing focus on safety issues.