Consequence Management Exercise: Applying Managing Rule Breaking

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Consequence Management Exercise Applying
Managing Rule Breaking
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• Incident descriptionThe accident happened at
  1030 hrs with a driver and three passengers
  travelling in a pick up. Whilst they were
  travelling to the base the driver fell asleep and
  the vehicle crossed the carriageway and hit the
  mountain on the left side of the road. After the
  impact the vehicle landed on its roof (rolled
  over 180 degrees) and finally rested 77 meters
  from the impact point.
• Outcome All the vehicle occupants were injured.
  Three of them were released from the hospital but
  the rear side passenger sustained major head
  injuries and passed away after four months in the
  hospital. The vehicle suffered extensive damage.
  Click here here to see a photograph and sketch
  from the place of an accident.

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(No Transcript)
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General Information

• Immediate cause
• Driver fell asleep behind the wheel while driving
• Main findings from investigation
• Driver had only 2.5 hours of sleep
• Journey Manager failed to challenge/recognize
  drivers fatigue
• Driver failed to apply Empowerment to Stop
• Driver failed to tell the passengers to wear
  seatbelt
• Driver was trained in Defensive Driving but not
  on PDO approved course.
• Journey Manager was not trained.
• Exercise Questions
• Who should have consequence management applied to
  them?
• What should the consequences be?

Summing Up Index
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Immediate Actions (PDO)
Summing Up Index
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Additional actions suggested by Hearts and Minds
Program
why
Summing Up Index
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why
why
Summing Up Index
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Journey Manager failed to challenge/recognize
drivers fatiguebecause,

• he believed that the driver was sufficiently
  rested and therefore did not need to intervene.
  MISTAKE
• I expected that he will return before 23.00 hrs
  and sleep till 04.00hrs when he will get up for
  prayer and breakfast.
• Journey Manager

Back to General information Incident description
Summing Up Index
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Driver failed to apply the Empowerment to Stop
because,

• he was afraid to loose his job. SITUATIONAL
  VIOLATION
• Interview with the driver suggests that he
  believed he no other choice and had to drive
• Q Why did you not tell the journey manager that
  you were tired and need some rest before the
  journey starts?
• A I was afraid of losing my jobs because xxx
  company always tells us we must always obey our
  supervisors without asking questions otherwise we
  will lose our jobs and this job is very important
  to me.
• (Car Driver)

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Summing Up Index
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Driver failed to tell the passengers to wear
seatbelt because,

• he was so tired he simply forgot. LAPSE
• Interview with the participants suggests that
  the driver usually asked his passengers to fasten
  their seatbelts
• Q Did the driver advice you to put on your
  seatbelts?
• A No, not on this journey. In the previous
  journey he asked us to use the seatbelt.
• Passenger

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Summing Up Index
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Driver only had 2.5 hours of sleep because,

• (Car Driver)
• he was afraid to loose his job. SITUATIONAL
  VIOLATION
• Interview with the driver suggests that he
  believed he no other choice and had to drive
• Q Why did you not tell the journey manager that
  you were tired and need some rest before the
  journey starts?
• A I was afraid of losing my jobs because xxx
  company always tells us we must always obey our
  supervisors without asking questions otherwise we
  will lose our jobs and this job is very important
  to me.

Back to General information Incident description
Summing Up Index
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Journey Manager was not trained  because,

• organisation did not place sufficient priority
  on training their journey managers before they
  started that role. ORGANISATIONAL OPTIMISING
  VIOLATION

Back to General information Incident description
Summing Up Index
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Driver trained in Defensive Driving Course but
not on PDO approved course  because,

• organisation did not ensure that all their
  drivers took an approved PDO course.
  ORGANISATIONAL OPTIMISING VIOLATION

Summing Up Index
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Summing up
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Other Questions Raised by using the tool

• Were other Journey Managers working without
  training?
• Why was this Journey Manager allowed to work
  without sufficient training?
• Did the Supervisor know that the Journey Manager
  was not trained? If not why not?
• Why did the Driver believe he could loose his job
  by refusing to drive?
• How can drivers be reassured that there is no
  personal consequences for them for refusing to
  driver for safety reasons e.g. fatigue
• Were the other drivers working without a valid
  PDO Defensive Driving Course? - Was that a common
  practice?
• Why did the company not sufficiently prepare for
  the Ramadan period, scheduling work to match the
  available resources?
• What are the safety leadership gaps, which allow
  these practices in Oman?

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