Académique Documents
Professionnel Documents
Culture Documents
C a r l R. Metzgar
Manager, S a f e t y and H e a l t h
Mideast D i v i s i o n
Vu1 can M a t e r i a1 s Company
135
Don't Waste An Accident
I
I keep six honest serving men
(They t a u g h t me all I knew):
There names are What and Why and When
And How and Where and Who.
Kipling, R.:
"The Elephant's Child,"1909
Figure 1 S1 ide 1
136
D o n ' t s t a r t w i t h an i n j u r y accident.
MAJOR INJURIES
MINOR INJURIES
INCIDENTS WITH
FIWRE 2 SLIDE 2
BYRO MIME SAFETY AN0 LOSS CO(ITR0L
S t a r t today a n a l y z i n g t h e nonserious. I t g i v e s p r a c t i c e so t h a t a t
l e a s t one person i s prepared, i f t h e r e i s a s e r i o u s i n j u r y , t o i n v e s t i g a t e
later. Work where t h i n k i n g has a chance. As t h i n g s s e t t l e down, progress
w i l l occur. D o n ' t be f o o l e d by a l l t h e noble thoughts and c o n v e n t i o n a l words
during a f a t a l i t y o r serious i n j u r y i n v e s t i g a t i o n . There a r e hidden agendas
a l l over t h e place. S i n c e r i t y appears t o be i n v e r s e l y p r o p o r t i o n a l t o t h e
nobi 1 it y o f t h e p l a t i t u d e s .
137
ACCIDENT RAT10 STUDY
I 0.1565
MAJOR INJURIES
10 + 1 = 11 MINOR INJURIES
1.7162
PROPERTY DAMAGE
ACCIDENTS
INCIDENTS WITH
NO APPARENT
INJURY OR
PROPERTY
4 DAMAGE
FIGUAE 3 U I O E 3
BYAO MINE SAFETY MO LOSS CONTROL
138
I f t h e i n t e g r i t y e x i s t s t o r e a l l y i n v e s t i g a t e t h e p r o p e r t y damage and
o t h e r i n c i d e n t s w i t h no i n j u r y o r damage v e r y soon t h e r e w i l l be so few
i n j u r i e s t h a t h a n d l i n g t h e emotion o f an i n j u r y a c c i d e n t w i l l be manageable.
For purposes here, " i n t e g r i t y " means asking t h e hard questions and committing
t o a p p r o p r i a t e c o r r e c t i v e a c t i o n s no m a t t e r where t h e answers lead. In air
crashes, t h e cause i s more o f t e n c o n v e n i e n t l y r e s o l v e d i n t o p i l o t e r r o r and
o f t e n misses t h e p o i n t .
I f t h e i n v o l v e d employee i s a v a i l a b l e , g e t h i s s t o r y - s e p a r a t e l y - f i r s t .
Have him t e l l and e x p l a i n . D o n ' t have him show. Take t h e notes o f what i s
volunteered, and o n l y a f t e r t h e employee has stopped t e l l i n g i s i t t i m e t o
s t a r t developing questions. The l a t t e r p a r t o f t h e paper i s about how t o
generate t h e questions. Prepare a statement f o r t h e i n v o l v e d employee t o
s i g n o r have him prepare it. F i x t h e f a c t s .
While t h i s e a r l y r e c o r d i n g o f t h e d e s c r i p t i o n o f t h e a c c i d e n t i s g o i n g
on someone e l s e should have been s e c u r i n g t h e a c c i d e n t scene and p r o t e c t i n g
t h e p h y s i c a l evidence. C r i t i c a l examination o f t h e p h y s i c a l t h i n g s has t o be
done. Physical t h i n g s change l e s s w i t h t i m e than memories. F i x t h e f a c t s .
139
everything not physical. I t has been s a i d b e f o r e . Look f o r t h e s i m p l e s t
e x p l a n a t i o n t h a t w i l l cover a l l t h e f a c t s . A complicated o r e x o t i c explana-
t i o n i s p r o b a b l y wrong. There w i l l be m u l t i p l e causes, each o f which w i l l be
simple. I n combination, t h i n g s w i l l be complicated.
I t i s u n l i k e l y t h a t t h e a c c i d e n t i n v e s t i g a t i o n r e p o r t form s u p p l i e d by
t h e s a f e t y department o r t h e insurance c a r r i e r , o r OSHA o r MSHA i s going t o
be much h e l p as a t o o l t o h e l p i n v e s t i g a t e . Most s u p e r v i s o r s ' f i r s t r e p o r t
o f a c c i d e n t forms a r e n o t u s e f u l i n t h e course o f t h e i n v e s t i g a t i o n . Most
r e p o r t forms (See Appendix A) by t h e i r design l i m i t q u e s t i o n s r a t h e r than en-
courage them. R e p o r t i n g i s a separate f u n c t i o n . Starting with the report
form k i l l s t h e i n v e s t i g a t i o n . By i t s nature, t h e r e p o r t form excludes f a c t s
r a t h e r than encourage t h e i r d i s c o v e r y .
140
The f i n a n c i a l and accounting people a r e v e r y f a m i l i a r w i t h t h e power o f
a spread sheet t o h e l p analyze a problem. The same idea i s t r a n s f e r a b l e t o
an a c c i d e n t i n v e s t i g a t i o n . Make a spread sheet.
FIWRE 6 SLIDE 6
Here i s a s t a r t f o r Who:
141
Keep i n mind t h a t what appears as an i t e m on a l i s t on t h e p r i n t e d page
i s r e a l l y t h e heading f o r a row and column. The same headings go down and
across. The c e l l s represented a r e t h e q u e s t i o n s t h a t have t o be answered.
The c o l l i s i o n o f two questions has t o be e x p l a i n e d and c l a r i f i e d .
WHO
EMPLOYEE
Age
S i z e ( H e i g h t and Weight)
Sex
Physical Condition
Education
Training
Experience i n P l a n t
Experience on Job
Language
Absenteeism
R i g h t h a n d e d / l e f t handed
EMPLOYEES SUPERVISOR
Age
Sex
Education
T r a i n i ng
Experience
PLANT MANAGER
Age
Sex
Education
Tra in ing
Experience
CO-WORKER #1
CO-WORKER #2
WITNESS #1
WITNESS #2
VENDOR
Education
Training
142
I' W ha t " is another set o f c e l l s t h a t needs s u b d i v i s i o n o r
mu1t i p 1 i c a t i o n . What was t h e f l o o r s u r f a c e where t h e a c c i d e n t occurred.
What was t h e equipment o r t o o l i n v o l v e d . What were t h e p a r t i c u l a r charac-
t e r i s t i c s o f t h e t o o l o r equipment t h a t c o n t r i b u t e d t o t h e a c c i d e n t o r k e p t
t h e a c c i d e n t from being even more s e r i o u s . Here i s a requirement f o r more -
columns and rows.
W HAP
-
S u p e r v i s o r Working o r s u p e r v i s i n g
P1a n t Manager
C a p i t a l Budget Proposed
C a p i t a l Budget Approved
Acquisition Price
Operating Cost
Weather
Tool s
Condition
I n s p e c t i o n Schedule
Bui 1d i n g
Bui 1d i n g F i x t u r e s
Instructions
Maintenance Manual
Vendors Updates
Maintenance Budget
WHEN
Day o f t h e week
143
Month of t h e y e a r
Time o f Day
Shift
A c t i v i t i e s one week p r e v i o u s
A c t i v i t i e s one month p r e v i o u s
A c t i v i t i e s one y e a r p r e v i o u s
A c t i v i t i e s f i v e years p r e v i o u s
When d i d he have h i s t r a i n i n g ?
WHERE
L o c a t i o n o f Witnesses
Location o f Accident/Incident
Location o f Supervisor
L o c a t i o n o f Helpers
L o c a t i o n o f Lockout
L o c a t i o n o f Tools
L o c a t i o n o f E l e c t r i c supply
L o c a t i o n o f Gas supply
L o c a t i o n o f Coal supply
Stored p o t e n t i a1 energy.
144
The questions generated so f a r a r e 4820 and how and why h a v e n ' t been
addressed s e p a r a t e l y .
Here e n t e r s i n t e g r i t y .
145
Human beings have very selective memories. We remember what we want t o
remember. Without the discipline of the spread sheet people are tempted t o
ask only the questions they want t o answer. There i s no d o u b t t h a t this
spread sheet will generate questions management would rather n o t face. That
i s why integrity i s so important.
Any series of 4200 questions i s going t o bump up against value judgments
and resource allocation questions t h a t will call for answers. Hard question-
ing will force some matching o f money and mouths.
An additional comment about "when". I t will most probably be found t h a t
the beginnings of the accident occurred much more than a week or month before
the actual incident. T h a t i s why the current and previous c a p i t a l and
operating budgets have t o be considered. There will have been financial
decisions t h a t precipitated physical responses from a worker w i t h days or
years separating decision and action. The decisions were abstract and the
results unexpected.
The discipline of going through a1 7 the interrelationships generated by
the spread sheet will develop questions t h a t would not ordinarily be asked.
Searching for reasonable explanations t o go with the questions will be most
productive. Following through t o a responsible conclusion w i l l take a large
measure of will power. There will be a natural tendency t o emphasize those
things t h a t can be found t o be someone e l s e ' s fault and minimize one's own
participation a
146
I n each o f t h e c e l l s t h a t r e p r e s e n t a c o l l i s i o n of two questions, answer
t h e how and why. That w i l l p r o v i d e more than enough i n f o r m a t i o n t o e x p l a i n
t h e how and why. The answers t o How and Why a r e i n t h e c o l 1 i s i o n s o f t h e
questions on t h e spread sheet.
147
,.I I -.."*I. ..
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3
P m1 MAIL THIS PAGE TO THE HEALTH AN0 SAFETY ANALYSIS CENTER. MINE SAFFTY
A N 0 MEALTH AOMINISTRATION. P.O.BOX -7. OENVER. COLOAAOO 802n
FIGURE 4 SLIDE 4
148
FIGURE 5 SLIDE 5
149
FIGURE 5A SLIDE 5A
150
REFERENCES
151