Learning the Lessons
Investigating incidents is a key part of any transport operation. Finding the truth about an incident is essential. Establishing the "Who, What, Where, When, How and Why"... Here we look at a few incidents where corporate investigations went wrong - and one where it went right.
We find that most organisations fall into the first three of four groups. In most cases the Who, Where and When are generally understood, but many organisations struggle with What and even more with How and Why.
Group 1: This group don't have a correct understanding of what happened in the incident and don't put the right mitigations in place, either for what they think happened, or for what did happen! Example: Following a crash in which a vehicle lost control and rolled over, the company decided that the vehicle had rolled because the aggressive off-road tread pattern on the vehicle's tyre had "not slid sufficiently" across the road surface as the vehicle spun and this had tripped the vehicle over. In fact, with any tyre on a vehicle undertaking the motion in question, the vehicle would have rolled at about the same point (confirmed with simulation). In response to this, the company had decreed that none of its vehicles were to be fitted with anything other than a road-biased tyre, which made an increase in off-road/dirt road incidents far more likely. Fortunately, their HSE department asked us to review the investigation and we were able to present a forensic reconstruction to their management which showed that the original investigation had been incorrect, and a structured argument for why the remedial mitigation would be a bad idea.
Group 2: This group put excellent controls in place after an incident, but base them on an incorrect understanding of the incident itself - in short, they get the "What and How" wrong. Example: Following a crash in which a vehicle had a burst tyre, a company put in place a very thorough and efficient process for ensuring that all vehicles had their tyres checked daily, that all tyres met the right specification for the vehicle they to which they were fitted and the operating climate, and that all new tyres were checked for date of manufacture to filter out old stock. The system was a positive contribution to their transport safety management, but did not address the actual cause of the incident. A review of the investigation found that the tyre has not burst and caused the crash (as claimed by the driver) but had burst as a result of impact damage against a rock as the vehicle crashed. The review found that the most likely cause of the crash was a loss of control by the driver due to alcohol consumption, but an ineffective initial investigation meant that this could never be proved. Whilst the tyre management process was a positive contribution to the safety management system, it did not address the causes of this incident, which were ineffective Driver Consequence Management and poor Journey Management.
Group 3: This group have a very good understanding of what actually happened in the incident itself but focus the "Why" question on the driver/s involved and so miss institutional learning points. Example: A company who had an excellent timeline of the incident, a good analysis of the movements of the vehicles as the collision took place, and a good assessment of what the driver could have done differently to avoid the incident. However, they had neglected to look at whether the journey was even necessary in the first place, when in fact it wasn't. The institutional issue was the lack of an adequate Journey Management system.
Group 4: This group generally have a good understanding of what happened in the incident, and apply good control measures as a result
Example: A home delivery business who had a vehicle parked in a layby which was hit in the rear by a third party driver travelling at speed, narrowly missing their own worker who was closing the rear doors. The company examined a range of factors, including where else their vehicle might have been parked and whether conspicuity markings might have made a difference. Many organisations, having concluded there was nothing they could have done to prevent the incident from occurring, would have stopped there. However, this organisation went a step further and realised even if the incident had still occurred, it was the presence of their driver at the rear of the vehicle that the vehicle which created the potential for a fatal injury to him. The solution? Coach built vehicle bodies with no rear doors, and all deliveries accessed from kerb-side doors only. A simple change to working practice and a workable engineering fix.
If you want to know more about how we assist organisations with everything from forensic level investigations to root cause analysis and Investigator Training packages, send an email to: firstname.lastname@example.org