EVERY EXCUSE IN THE BOOK: Making a case for Accident Investigation

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EVERY EXCUSE IN THE BOOK Making a case for
Accident Investigation

• Dr. Eric L. Van Fleet, CSHM
• Grand Valley State University
• Cook DeVos Center for Health Sciences
• Suite 200
• 301 Michigan Street, NE
• Grand Rapids, MI 49503
• 616.331.3687
• vanfleee_at_gvsu.edu
• www.gvsu.edu/osh

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Common, but faulty thinking
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Common, but faulty thinking
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Common, but faulty thinking
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Common, but faulty thinking
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Common, but faulty thinking
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Common, but faulty thinking
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Common, but faulty thinking
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Question What did they gain out of this
approach?
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Answer Nothing!

• Aftermath of a collision between a CAT 777 quarry
  truck and a passenger car

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Every Excuse . . .

• Accidents are the cost of doing business
• Investigations are time consuming
• Nothing ever changes after the investigation

• We know whos responsible for accidents
• Accidents are not a true picture

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What Constitutes an Accident?
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Was that an ACCIDENT?
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What can a (ACCIDENT) Critical Incident
Investigation do for you?

• It can give you a picture of how your
  countermeasures are working
• It can let you know when a given countermeasure
  has reached the end of its life
• It can provide insights into problems that have
  not yet produced significant loss
• It can assist you in a cost benefit analysis
• It can provide insight into needless human
  contributions

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Critical Incident Flowchart
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A quick journey
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First We Need To Decide What Constitutes An
Accident?

• Common Myth Definition
• Chance, Unplanned, Unforeseeable, Unavoidable
  (Officer, there was nothing I could do . . .
  Found in any standard dictionary)
• OSHA defines an accident as
• . . . any unplanned event that results in
  personal injury or in property damage. Found at
  www.osha.gov website

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Definitions cont

• Safety defines an accident as
• An unplanned or unintended event or series of
  events that may (a) result in death, or (b) cause
  environmental damage (c) adversely affect an
  activity or function (Lack, R. (2001) A-Z The
  Dictionary of Terms used in the Safety
  Profession. P1)
• Conceptual Accident Initial contact between two
  or more hazards in an unplanned state. Contact
  must represent a primary event (Van Fleet. E.
  (1993). Conceptual Models of Accident Causation.
  Conference Proceedings NOSH Conference 93)

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Then We Need To Decide The Role of Critical
Incident Analysis

• Good Roles
• Window into lack of proper planning
• Countermeasure assessment
• Are they doing their job
• Have they reached the end of their life
• Cost-Benefit Analysis
• Does the benefit out weigh the cost?

• Bad Roles
• To set blame
• To satisfy a governmental regulation
• To do it for appearance sake.
• To do it for appearance sake
• To label the incident strictly for the purpose of
  data storage.

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A Side Trip

• Before theory there were . . .
• Attitudes
• Casual Observations
• Limited Knowledge
• Of the relationship between work and accidents
• Of what humans can and can not do
• Of who is most responsible for accidents
• Of what accidents really cost us.

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Rate your job performance

• Excellent
• Good
• Average
• Poor
• Should be terminated

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Rate this workers job performance . . .

• Excellent
• Good
• Average
• Poor
• Should be terminated

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Attitude AssessmentBased

• Self Assessment
• 10 Excellent
• 70 Good
• 20 Average
• 0 Poor
• 0 SBT

• Other Assessment
• 0 Excellent
• 0 Good
• 0 Average
• 20 Poor
• 80 SBT

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This Fatal Incident Occurred Because

• The building was designed incorrectly
• Management failed to conduct appropriate training
• Management failed to provide adequate supervision
• Engineering failed to provide appropriate
  equipment
• The worker failed to understand what was
  happening
• The list goes on . . .
• This incident
• Killed one worker
• Injured two other workers and a customer
• Destroyed 1/3 of a facility
• Cost over 2.8 million in damages
• Cost additional millions in civil suites

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Attitudes vs. Research

• Research is unclear when it comes to attitudes
  and job performance
• Research is clear when it comes to
  knowledge/skill directed behavior and job
  performance
• The better informed, trained, and performance
  evaluated the worker . . . The better the job
  performance . . . The fewer the problems

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Who causes accidents?

• Rank order major contributors to accidents from
  the following choices
• 1Workers . . . 2Managers . . . 3Engineers
• Greatest Contributors
• 2nd Greatest Contributors
• 3rd Greatest Contributors

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Is this an Accident?
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Answer NO

• Why?
• Because the investigation will show that the
  parties involved in the planning and execution of
  the activity were able to have all the hazards
  they wanted to come together make contact.
• This was just a poorly planned and executed
  activity.

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Whats the Difference?

• A poorly planned or executed activity can produce
  desired results
• An accident represents the absence of planning
  and thus introduces things into an activity that
  dont belong
• Both are serious problems

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Rollerblader Revisited
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Incident Breakdown

• What constituted poor planning?
• Method of departure
• Landing surface-angle
• Etc . . .

• What constituted no planning?
• Objects located near landing site
• Types of injuries produced based on objects near
  landing site

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Critical Incident Analysis (CIA)

• A critical incident is any incident in which
  observers come to believe that what they are
  looking at is not what they should be looking at
• Critical incidents are marked by unexpected
  losses during the performance of an activity

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CIA Continued

• The losses may be a common part of the activity
• The losses may be an uncommon part of the
  activity
• The losses may be the result of an accident that
  occurred during the activity

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Critical IncidentView
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Closing Conditions
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Contact Phase
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Compounding Phase
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Countermeasure Approaches

• Prevention
• Severity Reduction
• Cleanup

• Only three basic types
• Each serves a specific purpose
• Each must be addressed before the activity is
  initiated to be of full value
• Each has a specific life

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Countermeasure Mistakes
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Prevention Countermeasures

• Role
• To keep hazards from coming together that we
  dont want to make contact
• Problem
• If we dont ask the right questions . . . We can
  confuse SR/CU with prevention

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Severity Reduction Countermeasures

• Role
• To bring down energy exchanges . . . To reduce
  losses associated with contact
• Problem
• If we dont ask the right questions . . . We can
  confuse P/CU with severity reduction

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Cleanup Countermeasures

• Role
• To reduce compounded losses often associated with
  an incident
• Problem
• If we dont ask the right questions . . . We can
  confuse P/SR with cleanup

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Fatal Fact Electrocution
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The Activity
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Critical Incident Investigation

• A Twelve Step Program
• Understand the need for the investigation
• Prepare for the investigation
• Gather the facts
• Analyze the facts
• Develop Conclusions
• Analyze Conclusions
• Make a report
• Make appropriate recommendations
• Correct the situation
• Follow through on recommendations
• Critique the investigation
• Double check the corrective actions
• Ferry (1998) Accident Investigation and Analysis

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Understand the Need

• Some Questions of Significance
• What do we want to accomplish?
• Do we want to prevent future incidents?
• Are there better ways for the job to be done?
• Who are we trying to satisfy . . . and why?
• Are we interested in pointing out problems or
  looking for solutions?

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Fact Gathering

• Collect information from the incident scene
• Collect information from witnesses
• Collect information from historical records
• JSAs
• Health Records
• Production Records
• Etc.

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Purpose of Analyzing Facts

• They suggest short, intermediate, and long term
  solutions
• They provide the user with a database that can
  provide a broader picture of events
• They guide the user in efficient data management
• They provide checkpoints in the questioning
  process
• They assist in establishing cost effective
  analysis activities

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Analyze Facts

• Place facts in a logical sequence of events
• Identify inconsistencies
• Reexamine facts that do not fit
• Determine what you dont know then seek
  additional facts

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Develop Conclusions

• Conclusions are based on what is know and what is
  not know
• Assess the seriousness of the deficiencies
• Conclusions should not be rank ordered

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Analyze the Conclusions

• Reanalyze each conclusion to determine its
  validity
• What supports it?
• What doesnt support it?
• Each conclusion represents a piece of information
  not an absolute

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Develop a Report

• This is usually the most difficult stage
• However it sets the foundation for management
  understanding and financial support
• Up to this point
• Information has been gathered and re-gathered
• Information has been analyzed and reanalyzed
• Conclusions drawn from, advanced, reviewed, and
  revised

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Report Recommendations

• The report should be brief, concise, and
  corrective in nature
• Provide a brief synopsis of what happened
• Place the incident in a chronological history
• Provide a picture by which the fact gathering,
  conclusions, and recommendations will follow
• Provide appropriate support media

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Make Recommendations

• The quality of recommendations is based on the
  incident analysis and such variables as
• Present Knowledge Base
• Economics
• Time
• Resources
• List corrective actions to be taken
• Rank order the corrective actions and indicate
  the rank order process

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Recommendations (cont)

• At issue in the rank ordering process is
• Cost vs. return
• Short term vs. long term impacts
• Responsibilities for implementation
• Countermeasure measurability

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Follow Through on Recommendations

• This is the recommendation assessment phase
• Assessment must be conducted to determine
• Are the countermeasures doing what they are
  suppose to do in the time frame they are suppose
  to do it in?
• Are the countermeasures creating expected
  problems (expected trade-offs) or unexpected
  problems?

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Critique the Investigation

• There must be a period set aside to evaluate the
  various stages of the investigation to determine
• What problems arose
• Why did the problems arise
• Is the data being stored properly
• Is the data being retrieved properly?

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Double Check Corrective Actions

• All countermeasures have a life
• As such
• All countermeasures must be periodically
  evaluated to determine if they are still doing
  their job.
• If not . . . Can they be adjusted?
• If not . . . They need to be eliminated

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Short Bib

• Ferry, Ted. (1996). Modern Accident Investigation
  and Analysis. John Wiley Sons. New York.
• Schulzinger, Morris S. The Accident Syndrome
  Charles C. Thomas Publisher, Springfield, IL.
  1956, 234 pages.
• Jacob, Suchman, et al, Behavioral Approaches to
  Accident Research, Association for the Aid of
  Crippled Children, New York, New York, 1966.
• Van Fleet, E.L. (1995). Use of an Environmental
  Safety Model for Dealing with Contemporary Pest
  Control. International Conference on
  Contemporary Pest Control Practices In Relation
  to Environmental Safety White Papers.
  Mansoura-Egypt

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If its worth doing . . . Its worth doing right!

• Why make life any shorter than necessary?