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Accident Investigation Gone Bad • A person worked at a computer manufacturing facility and also a licensed volunteer Emergency Medical Technician (EMT). One day the EMT was dispatched to a manufacturing buildings and found a young man that had suffered traumatic amputation of three fingers from his right hand. He was bleeding profusely, despite attempts by his fellow workers to stem the flow of blood. • As the EMT worked to apply the appropriate pressure bandages, he asked if anyone witnessed the accident. A man introduced himself as the injured man's supervisor and stated that he had witnessed the accident. • He related how the first man had gotten his hand stuck in the conveyor belt, while attempting to retrieve a part that had fallen between the belt and the running mechanism. • After the EMT completed applying the bandage and as the injured man was being loaded onto a gurney for transport to the ambulance and subsequently the hospital, the EMT asked the supervisor to show him where the accident happened. • They walked a few feet to the appropriate spot and the supervisor, without prompting, proceeded to show him exactly how the accident happened, even up the point of duplicating the incident by inserting his hand between the conveyor belt and running gears. • The supervisor lost two fingers!
Sources of Information • People. They need not be eyewitnesses or participants. They can be maintenance persons, doctors, supervisors, engineers, designers, friends, relatives, or anyone whose information can aid the investigation process. • Parts. This refers to failed machinery, communication system failures, inadequate support equipment, improper fuels and lubricants, or debris at the mishap site. • Position. This concerns the mishap location and involves the weather, roadway, operating conditions, and location, direction, wreckage resting position, and the like. • Paper. Paper performs as a witness through records, publication, tapes, directives, drawings, reports, and recordings. Nowadays we might also include computer software.
Record the Facts • Interview witnesses as soon as possible. • Document the accident scene before any changes are made. • Take photos • Draw scaled sketches • Record measurements • Gather support documents such as maintenance records, reports, production schedules or process diagrams.
Record the Facts • Keep all notes and remarks in a bound notebook or three ring binder. • Record: • Pre-accident conditions • Accident sequence • Post-accident conditions • Document victim location, witnesses, machinery, energy sources and other contributing factors.
Record the Facts • Even the most insignificant detail may be useful. • Document and then document some more. • The investigator should be concentrating solely on the investigation at hand.
Interviewing • Excellent source of first hand knowledge. • May present pitfalls in the form of: • Bias • Perspective • Embellishment • It is important to maintain a clear thought process and control of the interview.
Interviewing • Get preliminary statements as soon as possible from all witnesses. • Locate the position of each witness on a master chart (including the direction of view) • Explain the purpose of the investigation (accident prevention) and put each witness at ease.
Interviewing • Let each witness speak freely and take notes without distracting the witness (use a tape recorder only with consent of the witness). • Use sketches and diagrams to help the witness. • Emphasize areas of direct observation and label hearsay accordingly. • Record the exact words used by the witness to describe each observation.
Interviewing • Word each question carefully and be sure the witness understands. • Identify the qualifications of each witness (name, address, occupation, years of experience, etc.). • Supply each witness with a copy of their statements (signed statements are desirable).
Research Studies Involving Witness Reliability • How reliable are eye witness accounts of an activity? • Investigators often rely on information provided by eyewitnesses to determine the cause(s) of the accident and identify ways of preventing future mishaps. • However, the data on which accident investigators rely is error-prone.
Research and Eyewitnesses • There have been a number of research studies conducted which examine the reliability and validity of witnesses • Eyewitness memory for workplace accidents: Supervisors’ behavior compromises reports of occupational accidents • After a minor workplace accident, researchers measured recall and recognition memory for the accident. • The supervisor’s behavior influenced memory performance and productivity. • With direct implications for the product of occupational accident investigations, these results suggest that accident investigators should exercise caution when relying on eyewitness reports.
Research and Eyewitnesses • Research studies have also found differences in how the cause of the accident is perceived when questioning the injured person versus someone who witnessed the accident • This is referred to a “attributing the cause for the accident”
Fundamental Attribution Error • The fundamental attribution error involves placing a heavy emphasis on internal personality characteristics to explain someone's behavior in a given situation, rather than thinking about external situational factors. • The person got hurt in the accident because they were lazy, not because of a hazardous condition.
Actor-Observer Bias • This hypothesizes that “actors tend to attribute the causes of their behavior to stimuli inherent in the situation, while observers tend to attribute behavior to stable dispositions of the actor” • Witnesses more often tend to place the cause of the accident upon something the injured person was directly responsible for • Injured persons more often tend to place the cause of the injury upon an external factor that was out of their control
Self-Serving Bias • A self-serving bias occurs when people attribute their successes to internal or personal factors but attribute their failures to situational factors beyond their control.
Ultimate Attribution Error • Refers to a bias people commonly have towards members of an outgroup. • Specifically, they view negative acts committed by outgroup members as a stable trait of the outgroup, and view positive acts committed by outgroup members as exceptions to normal behavior.
Accident Investigation of a Safety Video Accident • The 52-year-old owner of a machinery and equipment training school violated the rule of following the safety rules while filming a forklift safety demonstration. • With the cameras rolling, he was thrown from the forklift cabin and crushed. • Subsequent investigation fingered the culprits responsible for the fatality: • Driver error and high speed over varied terrain coupled with an unused seat belt
