Question 1
(a) Examine the collected evidence for this incident and present them using the structure of the Swiss Cheese Model.
(b) You should present the layers of organisational influence, unsafe supervision, preconditions, and unsafe acts independently. Highlight your reasons for placing each item within the layer. You should also indicate where there are shortcomings in the evidence, the reasons why these shortcomings are so, and how they might be addressed (if possible).
(c) For all evidence that you use, you should illustrate actual and/or potential scientific verification, and you should formally cite the source(s).
(d) From this evidence, create a timeline of events that led up to the Pasir Ris Rail Accident and the loss of lives. Each element of the timeline should identify the evidences and layer of the Swiss Cheese Model these come from.
(e) You are free to use other additional tools to support your analysis, but if so, you should state your reason(s) for doing so.
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Question 2
(a) From the evidence gathered and your timeline with the Swiss Cheese Model created in Question 1, construct a Root Cause Analysis (RCA) for the incident.
(b) Identify the root cause(s) of the incident using a Causal Tree.
(c) From this Causal Tree and using the Hierarchy of Controls, compose your conclusion and recommendations to ensure that this incident does not happen again.
(d) Analyse the likelihood of success for each recommendation, presenting your rationale for this.
(e) You are free to choose the format of the recommendations. However, the format chosen should support the earlier assessment methodologies that you employed.
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Question 3
(a) Create a detailed report of this incident using the structure studied in this course i.e.
(i) What happened?
(ii) What caused it to happen?
(iii) What do you recommend should happen next?
(b) Your report should be in a form suitable for submission to the Board of a company as shown below:
Detailed Format
1. Table of Contents
2. Executive Summary – with Recommendations
3. Details of Investigation Team
4. Details of Incident
a. Summary of the Incident
b. Summary of evidence and data
i. Direct evidence
ii. Supporting documentation
iii. Interview evidence
5. Details of Analysis
a. Methods Used
b. Output from RCA
c. Unknowns, Uncertainties, and Controversy
6. Conclusions
7. Recommendations
a. To prevent reoccurrence of this type of incident
b. Expansion
i. Management System
ii. Geography
iii. Other jobs
iv. Other Companies
v. Other Industries
8. Appendices – as needed
a. Photos
b. Records
c. People involved d. etc.
