Accident Investigation Research Articles

Key Safety Rules During Safety Investigation – On The Example of Two International Organisations

The aim of the work is to look at the most important safety principles during the investigation of aviation accidents. Two international organisations dealing with civil aviation were selected to present the topic. The most important legal acts in the field of investigation of aviation occurrences issued by these organizations were analyzed. The most important safety principles were selected from these acts and then compared.

Rationalization plan for accident investigation procedures for defense safety accidents

Rationalization plan for accident investigation procedures for defense safety accidents

Sulfide Stress Cracking of column overhead pipe to flange fitting joints in a petroleum industry

The light hydrocarbon containment leakage in a petroleum industry overhead piping have caused severe fire explosion. This paper reports Sulfide Stress Cracking (SSC) in an overhead piping of splitter unit which separates out lighter components from heavier hydrocarbon. The failed overhead piping has been analyzed to determine the root cause of fire incident. The piping metallurgy was SS316L and chemistry of failed fitting components & its weld have been complied with NACE specification. Initially fittings were evaluated for intergranular corrosion to determine as-received material condition and confirmed defect free material. However, metallographic evaluation clearly evidenced transgranular brittle mode of cracking while hardness was higher than NACE specification (22HRC). Furthermore, virgin pipe joint was compared with damaged pipe joint for microstructural assessment. Moreover, actual service conditions were evaluated to obtain pH and H2S concentration in overhead condensed boot water. Microstructural factors have been discussed in detail as well. The results revealed that cold deformed austenitic structure attributed to SSC and undesired manufacturing steps were employed. Further, the root cause of an accident investigation also revealed failed components were not according to NACE specified metallurgy for sour service conditions.

Slicing Through the Layers of Pediatric Unintentional Injury With the Swiss Cheese Model: A Topical Review.

Pediatric unintentional injury significantly burdens children, families, and society. Behavioral researchers have examined the problem for decades, identifying many risk factors and greatly enhancing knowledge of the injury antecedent process. Approaches using theories and models to guide inquiry into etiology and prevention are still needed. We offer an approach borrowed from the field of human factors to enhance understanding and prevention. We focus our exploration on an error modeling and accident investigation tool called the Swiss Cheese Model. We first introduce the basic elements of the model. Next, we apply error modeling concepts to example scenarios drawn from real unintentional incidents and discuss the implications for understanding etiology and prevention. Finally, potential future directions are discussed to illustrate paths for the advancement of injury etiology and prevention.

Enhancing Brake System Evaluation in Periodic Testing of Goods Transport Vehicles through FTA-FMEA Risk Analysis

Failure of the braking system is one of the factors causing traffic accidents, therefore periodic testing of goods transport vehicles is very important. In fact, the incidence rate is still very high despite routine testing. Standard Operating Procedures (SOP) for periodic testing must be updated to reduce the risk of possible accidents. Therefore, procedures for updating the SOP for periodic brake system testing are presented in this article. The Fault Tree Analysis (FTA) and Failure Mode and Effect Analysis (FMEA) methods were applied based on accident investigation data from the National Transportation Safety Committee (NTSC) from 2017 to 2022. FTA is used for risk identification, while FMEA is used for risk analysis to find the highest-risk failure cases. The results of our analysis showed that 13 failure cases were classified as intolerable so additional SOPs were required for each case. Finally, the results of this study provide new insights for stakeholders to revise the rules regarding periodic vehicle testing.

Towards system-theoretic risk management for maritime transportation systems: A case study of the yangtze river estuary

This paper presents a novel framework for system-theoretic risk management of maritime transportation systems (MTS) based on the principles of formal safety assessment. The proposed framework comprises four essential steps: (1) risk identification: identifying accident scenarios and associated risk-influencing factors in the MTS through text mining of maritime accident investigation reports; (2) risk analysis: determining the probabilities and consequences of accident scenarios in the MTS using Bayesian network modeling; (3) risk evaluation: assessing the risks of various accident scenarios and the comprehensive risk of the MTS, and comparing the results with risk acceptance criteria to make informed decisions; and (4) risk treatment: proposing effective risk control options (RCOs) for accident scenarios and the comprehensive risk of the MTS by incorporating expert judgment, fuzzy sets, and Bayesian network modeling. To demonstrate the applicability of the proposed framework, the risk management of the Yangtze River Estuary is presented as a case study. By adopting a comprehensive approach to risk management, stakeholders gain a more holistic view of risk and achieve more effective decision-making processes for RCOs. The framework may help improve the safety and security of maritime operations, enhance the efficiency and competitiveness of the industry.

Cause Analysis of Coal Mine Gas Accidents in China Based on Association Rules

Coal mine gas accidents will cause great economic losses and casualties. It is of great significance to find out the essential causes of coal mine gas accidents and put forward measures to prevent them. In this paper, 110 coal mine gas accidents which occurred in China from 2001 to 2022 are selected to analyze the causes of the accidents by extracting the keywords of human factors, equipment factors, environment factors, and management factors from the accident investigation reports. Firstly, the accident statistical analysis is carried out from three dimensions of factor frequency, accident type, and accident grade. Secondly, the Apriori algorithm is used for data mining to obtain frequent item sets and association rules of coal mine gas accident factors. Finally, the coal mine gas accident cause chains which are obtained by using the association rule. The frequent terms of 9 factors, 23 association rules, and 3 coal mine gas accident cause chains are obtained. The results show that the production of coal mine enterprises by illegal organizations is an important reason for the occurrence of coal mine gas accidents. The lack of good management culture easily leads to habitual violations of personnel and decision-making errors, and then causes equipment problems, reflected in the ventilation system which is not perfect, resulting in gas accumulation. The occurrence of coal mine gas accidents can be prevented to a large extent by preventing the absence of good management culture in enterprise management and the occurrence of illegal production behaviors.

Investigation of the Relationship between Biorhythms and Occupational Accidents Severity in a Chemical Industry, 2009-2022

Introduction: Occupational accidents have several life and financial consequences in industries. Among the causes of accidents, human error and unsafe behavior are known as the most important factors. Studies showed that biorhythms affect human errors and occupational accidents. This study aimed to investigate the relationship between biorhythms and the severity of occupational accidents in the chemical industry. 
 Materials and Methods: This study investigated chemical industry accidents from 2009-2022. After removing the incomplete reports, 279 accidents report was collected. The investigated accidents were classified into two groups major and minor. Information related to the biorhythms cycles was analyzed using Natural Biorhythm software. Data analysis was done using SPSS-24.
 Results: The investigation of accidents showed that 115 and 164 people were involved in major and minor accidents, respectively. In this study, in the critical state of the intellectual cycle, the number of major accidents was significantly higher than minor accidents (P=0.009). In the investigation of morning shift work accidents, the relationship between the critical state of the intellectual cycle and the severity of accidents was confirmed (P=0.004). We found no significant relationship between physical and emotional cycles with the severity of accidents. 
 Conclusion: The results of the present study showed that the critical days of the intellectual biorhythm are related to the severity of occupational accidents. It is recommended to conduct more studies on different jobs and duties to clarify the exact relationships between the variables.

Critical Analysis of Container Accidents in International Logistics

Purpose: Container accidents are a significant issue in international logistics, causing property damage, financial loss, environmental hazards, and even loss of life. These accidents can occur in various settings, such as ports, container yards, roads, rails, or seas. Efforts are being made to enhance container safety, but they remain a persistent challenge that requires ongoing attention to ensure the safe and efficient movement of goods across the globe. By understanding the specific aspects of container accidents that are human-controllable and addressing these issues, a more sustainable and efficient global logistics industry can be achieved. Methodology: An exploratory research design is used in the research study. A comprehensive review of existing literature, including research papers, academic journals, books, reports, and reputable online sources was done. Literature that focuses on container accidents, maritime safety, human factors, and accident investigation reports was extensively studied to gain an understanding of the current state of knowledge on the topic. Data from relevant secondary sources that provide information on container accidents that are human-controllable were identified and collected. Results & Outcome: Container accidents that are happening owing to natural calamities such as floods, cyclones, sea perils, etc are uncontrollable. There are other forms of container accidents viz cargo damage, container equipment damage, container vessel damage, loss of life owing to container fall, etc occurring due to container sliding while handling, tipping of container vessels while loading, skewing of container vessels in the transit voyage, etc. that are controllable by human interference. Unevenly loaded containers seem to be the prime reason for many container accidents that are apparently controllable by humans by following the International Convention for Safe Containers (CSC) guidelines of the International Maritime Organization. In an LCL (Less than Container Load) scenario, adhering to such guidelines may be challenging. There are many research articles discussing the load balancing of containers in an LCL scenario using various optimization techniques, and it appears that the literature is still evolving. Originality: A exploratory study to understand the human controllable factors in container accidents, further study the regulatory guidelines, and analyse the research papers published. Type of the Paper: Exploratory research.

Investigation of Occupational Accidents in Mining with Survival Analysis

Investigation of Occupational Accidents in Mining with Survival Analysis

Accident investigation and lessons not learned: AcciMap analysis of successive tailings dam collapses in Brazil

Accident investigation and lessons not learned: AcciMap analysis of successive tailings dam collapses in Brazil

Legal Status of Accident Investigation Results of Space Activities in The Process of Enforcement of Space Law Enforcement in Indonesia: Between Procedural Justice and Substance Justice

Investigation findings and information obtained as a consequence of investigations cannot be treated as state secrets or utilized as evidence in court. This principle, which is followed by international aviation law, has generated controversy in Indonesian law enforcement practices, particularly when it comes to criminal and civil procedural laws, which acknowledge that the findings of investigations can serve as a foundation for further inquiries to identify suspects. The study’s findings revealed that, first, the ad hoc team’s philosophical investigation of space accidents within the framework of international law aims to determine the causes of spacecraft accidents to ensure that they don’t happen again in the future within the context of the main legal goal of benefit and justice for more people (the most people with the most happiness possible). While compensation claims are based on liability and without error (strict liability), police investigations as described in Articles 95 through 100 are intended to find criminal acts in space activities. There is no functional relationship between the two processes, so the findings of police or special team investigations cannot be used as the basis for carrying out legal actions. Given the obvious differences between the team’s investigation and the police’s investigation, there must be coordination between the technical team of the ministry and the police regarding the responsibilities and functions of these two institutions, each of which has a unique position and set of legal obligations. With this knowledge, it is believed that there won’t be any criminal prosecutions brought against the crews of spacecraft, similar to those brought against pilots in situations involving aviation accidents.

Handling Composites at Aircraft Accident Sites: An Evaluation of the Fracture Features in Burnt CFRP after the Application of a Fixant Solution

Aircraft accident investigations are paramount for the continuous improvement of aviation safety. As such, maximizing the amount of evidence that can be gathered from an accident site is critical. However, with composites being increasingly used for the construction of airframes, additional challenges are introduced into the handling of debris. Specifically, composites under combustion are known to release potentially noxious fibers and gases, posing a threat to individuals in the surrounding area. In response thereto, so-called fixant solutions (also referred to as hold-down solutions) can be used to minimize the release of inhalable fibers. Nonetheless, researchers have highlighted the risk for these solutions to interfere with the accident investigation process by masking, altering or even destroying fractographic features needed to determine the source or sequence of composite failures. Consequently, literature calls for more research focused on characterizing the influence of fixant solutions on the failure analysis of aeronautical composites. In this study, the impact of one form of fixant solution – namely, wetted water (i.e., water with a surfactant) – is evaluated. A [(0/90)]8 woven carbon fiber/epoxy composite sample is damaged in tension (representing an aircraft accident-causing failure), burnt (simulating an accident site fire) and doused in a wetted water fixant solution. The fracture surface is subsequently evaluated via a scanning electron microscope (SEM) and the condition of fractographic features relevant to the failure analysis is qualitatively evaluated. Through the findings of the study, a better understanding of the impact of a fixant solution on the failure analysis conducted during an aircraft accident investigation can be obtained. Moreover, the results can be used to develop protocols related to the handling of burning composites aiming to maximize both, the safety of individuals involved as well as the evidence needed to conduct a thorough investigation into the causal factors of an accident.

A methodology for crash investigation of motorcycle-cars collisions combining accident reconstruction, finite elements, and experimental tests

Motorcycle and in general motorized 2–3 wheelers accidents are a major concern of road safety worldwide representing about 28% of the overall fatalities. Speed is a central factor in the increase of injury severity of the accident’s intervenients. The main factors and causes of an accident can be determined with accident reconstruction being the reason for its popularity in accident safety research. A methodology of three different and complementary accident reconstruction methods is proposed and applied to a real accident where a motorcycle impacts the front side door of a passenger car. No other study in the literature presents a similar methodology for motorcycle accident reconstruction. With PC-Crash all accident dynamics were determined in the first place with a complete accident reconstruction. Afterwards, a finite element simulation of the impact between the motorcycle tire and the car’s door was conducted in Ansys LS-DYNA using all the results extracted from PC-Crash. The results of both these analyses correlated well with reality. To validate the finite element model, a pendulum experimental impact test was performed. It was achieved a good correlation from a kinematic point of view. An accurate accident reconstruction and a correct validation of the kinematics are possible with the proposed methodology. A good correlation of results between the three different methods was achieved. The proposed methodology enables for a more accurate estimation of the speed of motorcycles involved in accidents which is of extreme importance in accident investigation.

Integrating Information Entropy and Latent Dirichlet Allocation Models for Analysis of Safety Accidents in the Construction Industry

Construction accident investigation reports contain critical information, but extracting useful insights from the voluminous Chinese text is challenging. Traditional methods rely on expert judgment, which leads to time-consuming and potentially inaccurate results. To overcome this problem, we propose a novel approach that combines text mining techniques and latent Dirichlet allocation (LDA) models to analyze standardized accident investigation reports in the Chinese construction industry. The proposed method integrates an information entropy term frequency-inverse document frequency (TF-IDF) weighting scheme to evaluate term importance and accounts for word and model uncertainty. The method was applied to a set of construction industry accident reports to identify the key factors leading to safety accidents. The results show that the causal factors of accidents in Chinese accident investigation reports consist of keywords and negative expressions, including “failure to timely identify safety hazards” and “inadequate site safety management”. Failure to timely identify safety hazards is the most common factor in accident investigation reports, and the negative expressions commonly used in the reports include “not timely” and “not in place”. The information entropy TF-IDF method is superior to traditional methods in terms of accuracy and efficiency, and the LDA model that considers word frequency and feature weights is better able to capture the underlying themes in the Chinese corpus. And the subject terms that make up the themes contain more information about the causes of accidents. This approach helps site managers more quickly and effectively understand the causal factors and key messages that lead to accidents from incident reports. It gives site managers insight into common patterns and themes associated with safety incidents, such as unsafe practices, hazardous work environments, and non-compliance with safety regulations. This enables them to make informed decisions to improve safety management practices.

Nondestructive Forensic Investigation of a Scissor Lift Fatality

After a worker was found fatally pinned between the top rail of a scissor lift and an overhead beam, rescue attempts were frustrated by unresponsive lift controls. In the investigation of this fatal accident, certain lift controls did not function or functioned intermittently. The intermittent nature of the malfunction indicated that the evidence was sensitive — likely to be disturbed if the device was disassembled using typical destructive techniques. Therefore, nondestructive techniques were required. This study discusses how X-ray imaging, computed tomography (CT), electrical testing, and engineering analysis of the lift and control system were used to investigate the causes and contributing factors of this fatal accident without disturbing sensitive evidence.

Virtual Reality's Effects on Air Crash Accident Investigation Learning Interaction

The objective of this study is to gain a deeper comprehension of the factors that play a role in the evolution of virtual reality (VR) for application in the investigation of aviation disasters. This study was motivated by the concept of utilising VR to create an illusion of the procedures involved in an anviation accident. A conceptual model has been presented, to create the scene that will be simple to understand the procedure of accident following an air crash. The idea is to compile a series of steps that an investigation team will go through and then present them in VR. This stage entails obtaining complete views of the object before it crashes and at ground level. This study contributes to the process of creating the groundwork for adopting VR in air crash investigations to provide instructional experiences. The idea that was presented in this research focuses on feature of the surrounding area of the crash or accident, wreckage distribution, wreckage above the ground, wreckage in motion, wreckage at the ground, spatial view effect, and full view projection as the primary VR features that are required for teaching and learning about air crash accident investigations using VR.

Virtual reality's effects on air crash accident investigation learning interaction

The objective of this study is to gain a deeper comprehension of the factors that play a role in the evolution of virtual reality (VR) for application in the investigation of aviation disasters. This study was motivated by the concept of utilising VR to create an illusion of the procedures involved in an anviation accident. A conceptual model has been presented, to create the scene that will be simple to understand the procedure of accident following an air crash. The idea is to compile a series of steps that an investigation team will go through and then present them in VR. This stage entails obtaining complete views of the object before it crashes and at ground level. This study contributes to the process of creating the groundwork for adopting VR in air crash investigations to provide instructional experiences. The idea that was presented in this research focuses on feature of the surrounding area of the crash or accident, wreckage distribution, wreckage above the ground, wreckage in motion, wreckage at the ground, spatial view effect, and full view projection as the primary VR features that are required for teaching and learning about air crash accident investigations using VR.

Research of Indoor Methane Mass Fraction and Explosion Hazard Prediction Model Based on EKF

In order to realize the intelligence of the indoor methane supervision system and to deeply analyze and apply the data collected by sensor devices, this paper predicts the indoor methane mass fraction by extended Kalman filter and realizes the prediction of explosion consequences by TNT equivalent method, so as to establish an indoor methane warning model for data collection and analysis. And taking a room of 3×3×3m3 as an example, the indoor natural gas leakage is simulated by CFD, and the data of methane mass fraction change with time is obtained for model simulation and explosion consequence prediction calculation. It is found that the Kalman filter can predict the dynamic change of methane in the room, and the methane concentration in the room gradually reaches the equilibrium state after 10,000s, and the concentration is stable at 3%. The calculation results can provide direction for the accident investigation and provide reference for the decision of accident disposal.

SMART CONTRACT IMPLEMENTATION USING BLOCKCHAIN IOV FOR VEHICLE ACCIDENT INVESTIGATION

Recent advancements in digital accident forensics, a conceptual evidence management paradigm developed using smart contracts and interplanetary file system in iov. This paper comprehensively summarizes the Smart contract implementation blockchain framework for vehicle accident investigation in IoV. We investigate comparing some review papers to find the classification of the smart contract. Using blockchain, evidence management provides an immutable and auditable method for investigating and resolving accident cases. Precisely we first investigate the security and privacy threats; therefore, Smart contracts provide effective access control for proof data and reports. On both the public and private Ethereum blockchains, the cost of setting up and executing transactions using smart contracts is assessed. However, we utilized the Inter Planetary File System most efficiently while minimizing memory and execution costs. Finally, we draw open research directions for building future digital-proof management.