HFS353 Incident and Accident Investigation Assignment: Root Cause Analysis and Safety Recommendations for the 2004 Nicoll Highway Collapse

Question 1

This end-of-course project aims to gauge your ability to

(1) analyse the potential that exists for incident and injury investigation;
(2) examine the necessary preparations to deal with an incident and injury investigation;
(3) illustrate the purpose of incident and injury investigations and assess their suitability;
(4) indicate resources and expertise that may need to be involved to conduct an investigation;
(5) compose and prioritise recommendations; and
(6) Create a structured incident report.

Read the case study below before you attempt the questions.

Nicoll Highway Collapse Accident, Singapore, 20 April 2004

The Nicoll Highway collapse occurred in Singapore on 20 April 2004 at 3:30 pm local time when a Mass Rapid Transit (MRT) tunnel construction site linking to Nicoll Highway station caved in along with a 100-metre (300-foot) stretch of Nicoll Highway, leading to the collapse of the Nicoll Highway near the Merdeka Bridge.

Four workers were killed and three were injured, delaying the construction of the Circle Line (CCL).

The incident happened when most of the workers were on a tea break. The collapse of a tunnel’s retaining wall created a huge hole (100 m long, 130 m wide, and 30 m deep).

A foreman who had helped evacuate his workers to safety when the site collapsed did not escape in time because a flight of exit stairs collapsed. Three injured workers were taken to the hospital for treatment; two of them were discharged the same day. No motorists were driving along the stretch of road when it collapsed, and others stopped in time.

You are to conduct an accident investigation to determine the causes of the above accident based on evidence that has already been established. You are NOT expected to uncover new evidence; instead, your analysis should rely solely on publicly available and accessible sources.

Using the concepts and methodologies taught in this course, you are to collect and examine the relevant data, identify the root cause(s) of the incident, and develop recommendations to prevent similar occurrences in the future.  Your incident report should be in a form ready for submission to the company management, as shown below:

Detailed Format

1. Investigation Report Cover Page

2. Table of Contents

3. Abbreviations

4. List of Figures

5. List of Tables

6. Synopsis

7. Factual Information.

This can include information from documentation, records, checklists, Standard Operating Procedures, policies, acts, standards, and interviews. The factual information should be presented in the following format:

a. Timeline: Include a timeline of events that led to the accident and the loss of lives.
b. Injuries to people.
c. Damages to equipment/structure/facilities/others.
d. Personnel information (License/Certification/Qualifications/Experiences/Dutytime/Rest Period/Others)
e. Equipment operation
f. Meteorological information
g. Communication
h. Emergency responses
f. Fire and fire-fighting ii. Evacuation III. Barricade
i. Tests and research

8. Analysis

a. Examine the factual information for this incident and identify the HFACS factors.
b. Present the factors with reference to the layers of Organisational Influence, Unsafe Supervision, Preconditions, and Unsafe Acts.
c. Indicate where there are limitations in the evidence, the reasons for the limitations, and how they might be addressed (if possible).
d. For all evidence. show actual and/or potential scientific verification. Cite all the sources using the American Psychological Association (APA) 7th edition format. 
e. Unknowns, Uncertainties, and Controversy.

9. Conclusions of Analysis

10. Safety Actions

• From the factual information and HFACS analysis, compose the safety actions taken to ensure this incident does not happen again.

11. Safety Recommendations

• From the factual information and HFACS analysis, use the Hierarchy of Controls to propose recommendations to ensure that this incident does not happen again.
• Evaluate all recommendations and prioritise based on the likelihood of success for each recommendation. Present your evaluations clearly.

12. Expansion.

• From the Safety Actions and Safety Recommendations, illustrate how these actions and recommendations may apply to: a. Other Countries

a. Other Jobs
b. Other Companies
c. Other Industries

13. Appendices.

You can include the following information if it is relevant:

a. Photos
b. Records
c. People involved

14 References

The following assessment rubric will be used:

(100 marks)