D o n ' t Waste an A c c i d e n t

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

May 22, 1990

135
 Don't Waste An Accident

When lightning was classified as "evidence of divine wrath" no courses

of action other t h a n prayer were suggested t o prevent one's being struck by
lightning. As soon, however as i t was classified as "electricity" Benjamin
Franklin achiev a measure of control over i t w i t h his invention of the
lightning rod. I n this case, assigning a proper name o r a t least a
neutral name was a key t o progress.
The same t h o u g h t pattern revolves around accidents. So long as i t i s
believed t h a t accidents just happen, are o u t o f c o n t r o l , and t h a t there is
nothing t o do about them, etc. Nothing will be done about them. No one w i l l
even think about making changes for the better.
If on the other hand i t i s believed t h a t "An accident i s an undesired
event t h a t r ults i n harm t o people, damage t o property, or loss t o
process", (?! then there i s something t o be done. Isolating and analyzing
the interruption and i t s multiple causes can lead t o change.
There i s a method for investigating. I t begins ith questions, it
develops with questions, and i t ends with questions. ( 37

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

To get maximum u t i l i t y o u t of an accident, s t a r t w i t h t h i n k i n g . Could one

suggest t h a t each minutes thought can save a hour's running around. Assume
the s l a t e i s clean. The pledge t o investigate accidents i s sincere and a l l
involved want t o do a good j o b . Where does one s t a r t . One starts w i t h a
particular incident. S t a r t w i t h a near miss or a property damage accident.
I f one starts here, there i s no danger o f a long wait. Plants go f o r weeks
o r months w i t h o u t serious injuries, b u t the roof i s leaking and the metal i s
crunching right now. Yes, b o t h f a l l i n t o the definition o f accident just
given.

136
 D o n ' t s t a r t w i t h an i n j u r y accident.

ACCIDENT RAT10 STUDY

MAJOR INJURIES

MINOR INJURIES

INCIDENTS WITH

FIWRE 2 SLIDE 2
BYRO MIME SAFETY AN0 LOSS CO(ITR0L

Everybody g e t s e x c i t e d about a s e r i o u s i n j u r y a c c i d e n t . The g r e a t e s t

p i t f a l l i n s e r i o u s i n j u r y a c c i d e n t i n v e s t i g a t i o n i s t h a t t h e emotional
q u o t i e n t i s sky high. The more s e r i o u s t h e i n j u r y the rriore emotion. If
t h e r e i s a f a t a l i t y , t h e r e i s more i n t e r f e r i n g h e l p than anyone knows what t o
do w i t h . O r d i n a r i l y c l e a r t h i n k i n g managers go i n t o o r b i t o v e r an i n j u r y .
There i s no p o i n t i n mouthing p l a t i t u d e s . The more emotion t h e l e s s l i k e l y
t h a t good c l e a r t h i n k i n g w i l l make a c o n t r i b u t i o n o r i t w i l l t a k e a l o n g t i m e
f o r r i g o r o u s f a c t f i n d i n g and a n a l y s i s t o make i t s e l f f e l t .

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

How i s emotion t o be taken o u t of an accident investigation? Here i s a

socially and politically unacceptable answer.
I f a l l the serious injury accidents were never investigated there would
only be a 1.71% loss of information. Since the difference between a serious
injury accident and any other class of accident i s luck anyway, you haven't
lost much. If you only investigate the one accident a t the t o p o f the -
pyramid, the one represented by serious injuries you have only looked a t
0.156% of your incidents. I t i s doubtful that the 0.156% serious or i . 7 6 ,
serious and minor injuries are representative o f w h a t i s g o i n g on i n your
p l a n t in any case. If only serious injury accidents are investigated, the
whole place i s all tore up over the wrong problem. I t has t o appear t h a t you
are paying inordinate a t t e n t i o n t o injury accidents when i n fact the real
useful information i s somewhere el se. An accident prevention program based
on the results of serious injury accident investigation w i l l ultimately f a i l .
I t will not point the r i g h t direction. There i s a risk o f getting bogged
down in trivia i f you only try t o concentrate on the 600.
T h a t brings us t o the prgperty damage accidents or the incidents w i t h no
injury or visible property damage. The number of opportunities for inves-
tigation i s very large an,d there i s no emotional quotient t o deal w i t h . No
matter how serious the property damage i t can be fixed w i t h money. I f you
hgve a problem t h a t can be fixed w i t h money you don't have a problem. No
matter how minor the i n j u r y , you can't fix i t with money. When money w o n ' t
f i x i t you have a problem. Perspective i s most important as you assign
resources t o investigating these cases. I t i s n o t likely t h a t you w i l l
realistically do a detailed investigation o f 600 accidents i n a year even i f
you could f i n d them.
T h a t brings us t o integrity. I n accident investigations and subsequent
actions, integrity i s the key factor, ingredient, motivating force or
whatever i t i s t o be called.

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 .

"The tenacious r e t e n t i o n o f ' p i l o t e r r o r ' as an a c c i d e n t

' c a u s e / f a c t o r ' by governmental agencies , equipment manufac-
t u r e r s , and a i r l i n e management, and even by p i l o t unions i n -
d i r e c t l y , i s a s u b t l e manifestation o f the apparently natural
human i n c l i n a t i o n t o narrow t h e r e s p o n s i b i l i t y f o r t r a g i c
events t h a t r e c e i v e wide p u b l i c a t t e n t i o n . I f t h e respon-
s i b i l i t y can be i s o l a t e d t o t h e momentary d e f e c t i o n o f a
s i n g l e i n d i v i d u a l , t h e c a p t a i n i n command, t h e n t h e o t h e r
members o f t h e a v i a t i o n community w i l l remain untarnished.
The unions b r i e f l y acknowledge t h e inescapabl e concl u s i on
t h a t p i l o t s can make e r r o r s and thereby n a few b a r g a i n i n g
p o i n t s w i t h management f o r t h e f u t u r e . "

The c a p t a i n o f t h e Valdez was f i r e d , b u t t h e p r e s i d e n t o f Exxon wasn',t

affected. There were management system f a i l u r e s way beyond t h e a c t i o n s of
t h e c a p t a i n b e f o r e and a f t e r t h e i n c i d e n t . I n t h a t case i n t e g r i t y l i k e
j u s t i c e had a b l i n d f o l d .

I n j u r y , damage, o r near miss how do we proceed.

The medical needs o f t h e people come f i r s t . Once those a r e met, there

i s t i m e and energy f o r o t h e r c o n s i d e r a t i o n .

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 .

Next go t o t h e witnesses, i f t h e r e a r e any, and g e t t h e i r s t o r i e s -

separately. Make y o u r notes. Only a f t e r t h e s t o r y runs o u t i s i t t i m e t o
s t a r t a s k i n g questions. Developing q u e s t i o n s and c a t e g o r i e s o f questions
came from t h e s i x honest s e r v i n g men a t t h e beginning. Prepare a statement
f o r t h e witnesses t o s i g n o r have them prepare t h e i r own. 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 .

The a c c i d e n t i t s e l f can be f i x e d i n t i m e and place. The evidence i s

p h y s i c a l and can be looked a t and t e s t e d . O r d i n a r y p h y s i c a l laws apply t o
any e v a l u a t i o n t h a t i s done on t h i n g s . S u b t l e judgment has t o be a p p l i e d t o

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.

The f i r s t r u n a t t h e v i c t i m , witnesses, and evidence a r e most important.

As t i m e goes on, changes i n d e t a i l s w i l l show up t h a t may be s i g n i f i c a n t o r
i r r e l e v a n t , b u t changes w i 11 occur. P i n down t h e f a c t s as e a r l y as p o s s i b l e .
Memory i s f a l l i b l e and unre i a b l e w t h time. Do t a k e w r i t t e n statements as
soon as p o s s i b l e .

The p h y s i c a l evidence w 11 t e l l i t s s t o r y i f examined p r o p e r l y . The

p h y s i c a l evidence may show a p i c t u r e d i f f e r e n t from t h e s t o r y o f p a r t i c i p a n t s
and witnesses. The f a c t s from t h e d e s c r i p t i o n o f thoughts, a c t i o n s , and ob-
s e r v a t i o n a r e s o f t t o b e g i n w i t h and g e t more e l u s i v e w i t h time.

A character i n a r e c e n t novel make he o b s e r v a t i o n t h a t , "A f a c t has

t h r e e sides and a thought has s i x " . f 5 f A l l s i d e s a f f e c t t h e r e s u l t o f t h e
i n v e s t i g a t i o n . The i n v e s t i g a t i o n s a r e n o t immune t o t h e e f f e c t of successive
developments. You have d i s c o v e r e d by t h i s p o i n t t h a t f i x i n g f a c t s i s d i f -
f i c u l t.

The f i r s t and second phases o f t h e i n v e s t i g a t i o n a r e now complete and

t h e hard work i s about t o begin. Follow-up t o c o n f i r m t h e f a c t s . Work t o
develop t h e f a c t s t h a t a r e missing.

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 .

From t h e beginning, t h e i n v e s t i g a t i o n i s t o g a t h e r f a c t s and leads.

Make c e r t a i n t h a t t h e d i f f e r e n c e between f a c t and o p i n i o n i s c l e a r . An
o p i n i o n can be a l e a d and once i t i s i n v e s t i g a t e d i t can c o n t r i b u t e useful
i n f o r m a t i o n o r i t can be t h e f i r s t s t e p down a deadend. Q u e s t i o n i n g i s most
important.

While gathering thei n f o r m a t i o n i t i s i m p o r t a n t n o t t o ignore,

el i m i n a t e , o r throw a n y t h i n g away. Subsequent development of f a c t s may
change an e a r l i e r i n t e r p r a t i o n o f t h e f a c t s . "One t r a n s f e r r e d d e t a i l , . . ,
can change many t h i n g s . " (8 Q u e s t i o n s and s u b d i v i s i o n o f q u e s t i o n s w i l l
produce t h e f a c t s and d i r e c t i o n s t o new f a c t s t h a t w i l l be p r o d u c t i v e . Ques-
tions are the d r i v i n g force o f the investigation.

Since i t i s hard t o remember a71 t h e questions, and a p r e p r i n t e d i s t o f

questions i s n o t l i k e l y t o be a v a i l a b l e j u s t when i t i s needed, t h e r e has t o
be a d i f f e r e n t p l a c e t o s t a r t . A blank sheet o f paper and an a c t i v e m nd are
s u p e r i o r t o t h e b e s t a c c i d e n t r e p o r t form i n t h e world.

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.

The poem a t t h e beginning names t h e s i x questions f o r the columns and

rows. Who? When? What? Where? How? Why?

FIWRE 6 SLIDE 6

W r i t e those q u e s t i o n s across t h e t o p o f a columnar pad and w r i t e t h e

same questions down t h e l e f t hand s i d e . The g r i d has 36 c e l l s . S u b t r a c t t h e
s i x where t h e q u e s t i o n s cancel each o t h e r out. There i s no need f o r a Who-
Who o r a How-How. The remaining 30 c e l l s c a l l f o r a response.

The 30 c e l l s a r e n o t r e a l l y adequate t o generate enough q u e s t i o n s t o

s a t i s f y an i n v e s t i g a t i o n . The t h i r t y c e l l s a r e t o o general and have a l l t h e
l i m i t a t i o n s o f 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 forms. To ask e v e r y t h i n g ,
i s t o ask nothing. F u r t h e r steps a r e needed t o extend t h e sheet.

The 30 c e l l s ask more q u e s t i o n s than t h e r e p o r t forms and t n t inadequacy

o f t h i s l i m i t e d g r i d i s immediately apparent. The r e p o r t form l o o k s good
( s u b s t i t u t e f a m i l i a r ) and t h e g r i d l o o k s strange. Go f o r r e s u l t s .

"Who" ( s u b d i v i d e d ) would i n c l u d e t h e i n j u r e d , h i s s u p e r v i s o r , and t h e

supervisors supervisor. Who would i n c l u d e t h e i n j u r e d ' s age, experience i n
the c u r r e n t j o b , t h e p l a n t , and t h e i n d u s t r y . Think about how Who c o u l d i n -
c l u d e t h e t r a i n e r f o r t h e o r i g i n a l MSHA new m i n e r t r a i n i n g , t h e &hour
r e f r e s h e r , and t h e t a s k t r a i n i n g .

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

Manning Table f o r p l a n t people assigned t o t h e

job.

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

What was t h e employee doing?

-
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

What equipment was i n v o l v e d - Fixed

- Mobile

C a p i t a l Budget Proposed
C a p i t a l Budget Approved

Operating Budget Proposed

Operating 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 was t h e employee absent l a s t ?

When was t h e employee absent t h e t i m e b e f o r e t h a t ?

When were co-workers absent l a s t ?

When were co-workers t i m e b e f o r e t h a t .

When was a s u p e r v i s o r absent l a s t ?

When d i d he have h i s t r a i n i n g ?

When was t h e equipment l a s t inspected?

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 .

The r e s u l t o f many t h i n g s working t o g e t h e r o r a p a r t have r e s u l t e d i n an

undesired event o r an i n t e r r u p t i o n . The how and why i s what t h e search i s
a l l about. The search i s f o r those t h i n g s i n t h e management system t h a t can
be adjusted. The management system i s w i t h i n t h e c o n t r o l o f management.

Here e n t e r s i n t e g r i t y .

I t has been c o m f o r t i n g f o r many y e a r s t o hear t h e r e p e t i t i o n o f "85% t o

96% o f accidents a r e caused by unsafe a c t s " . Comforting because when many
managers heard these words t h e message r e g i s t e r e d was "those people j u s t keep
making mistakes". They keep doing t h i n g s wrong.

"To say t h a t a c c i d e n t s a r e due t o human f a i l i n g i s n o t so

much u n t r u e as u n h e l p f u l . I t does n o t l e a d t o any construc-
t i v e a c t i o n ; a l l we can do i s t e l l someone t o be more care-
ful. I n c o n t r a s t , i f we say t h a t an a c c i d e n t can be
prevented by b e t t e r design, o r by b e t t e r t r a i n i n g o r i n s t r u c -
t i o n o r by b e t t e r a u d i t i n g o r
t h a t may p r e v e n t a recurrence." i 95
p e c t i o n we can t a k e a c t i o n

I t i s probable t h a t management has the brains to find the

i n t e r r e l a t i o n s h i p s o f t h e q u e s t i o n s generated by t h e spread sheet. The ques-
t i o n i s , "Does management have t h e i n t e g r i t y t o f a c e t h e f a c t t h a t i t s
managers d e c i s i o n s can be r e s p o n s i b l e f o r t h e s i t u a t i o n t h a t a worker has t o
face t h r e e years l a t e r ? " , i s much harder t o answer.

I t i s most i m p o r t a n t t o complete a l l t h e columns and rows and t o keep

t r a c k o f them t o make c e r t a i n t h a t t h e r e l e v a n t q u e s t i o n s generated a r e
answered. The reason f o r l i s t i n g t h e b a s i c q u e s t i o n s and then t h e s u b d i v i -
sions i s t o f o r c e t h e i n v e s t i g a t o r t o e v a l u a t e as many i n t e r a c t i o n s as
p o s s i b l e r a t h e r t h a n as few as p o s s i b l e . Handle each i n t e r r e l a t i o n s h i p
represented by a c e l l on t h e sheet.

There i s no q u e s t i o n about t h e f a c t t h a t t h e use o f a spread sheet makes

work. However, i t i s n o t a "make work" p r o j e c t . I t i s a make q u e s t i o n
p r o j e c t . Each q u e s t i o n i s t h e o p p o r t u n i t y t o f i n d o u t something t h a t w i l l be
useful. Each q u e s t i o n p o i n t s toward a f a c t t h a t can be i s o l a t e d , measured,
tested, and f i t i n t o t h e puzzle. Provided t h e r e i s i n t e g r i t y , o l d ideas and
p r e j u d i c e s w i l l be questioned, and e i t h e r confirmed, o r found t o be
inadequate.

I t i s v e r y l i k e l y t h a t i n g e n e r a t i n g a spread sheet t h a t w i l l propose

more than 4200 questions some o f them w i l l be pure nonsense. However some o f
t h e questions w i l l show unexpected r e l a t i o n s h i p s . I f the investigator i s
s t r a i g h t forward and management i s r e s p o n s i b l e , i t w i l l be found t h a t t h e r e
were m u l t i p l e unsafe a c t s . Management f a i l u r e s w i l l a l s o be found. The
management f a i l u r e s can n o t be passed over.

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

Some most unpleasant facts will have t o be faced.

.Don't quit a t the f i r s t or even second cause. Keep looking until those
things are found t h a t can be changed and improved. Follow-up i s unexciting
and unromantic, b u t there is no known substitute for i t .
Find the problems i n the system and fix the system. There has not been
much successful change worked on people over the l a s t 2,000 years. There has
been a l o t of progress in changing equipment and systems t o limit the error
potential of human beings and the effects of those errors.
Face the unpleasant questions and get the facts.
For those c r i t i c s who t h o u g h t t h a t there was no
point i n gathering d a t a , because they would be
misinterpreted Charles Babbage the computer
precursor said: "The errors w h i c h arise from the
absence of facts are f a r more numerous and durable
than those w h result from unsound reasoning from
true d a t a .
1'

How and Why

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.

As engineering, f i n a n c i a l , and o p e r a t i n g managers, you a r e n o t s u r p r i s e d

t h a t a l l t h i s r e s o l v e s i t s e l f i n t o a q u e s t i o n o f money.

Some m i g h t say t h a t a f t e r e l i m i n a t i n g Who Who and How How i t would be

wise t o reduce t h e questions by h a l f by agreeing t h a t "Who-When" i s equal t o
"When-Who." I f i t i s f a c t s t h a t a r e t o be gathered, these p a i r s a r e n o t
equal.

I n w a l k i n g around t h e p l a n t , i f t h e same p a t h and t h e same d i r e c t i o n a r e

f o l l o w e d a 50% o f t h e o p p o r t u n i t y i s l o s t f o r changing a p o i n t o f view.

Opinions a r e d i f f i c u l t t o deal w i t h . The f a c t s w i l l d e l i v e r t h e i r own

message. The s i x honest s e r v i n g men w i l l c l e a r t h e way and l i m i t t h e load.

147
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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

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FIGURE 5 SLIDE 5

149
FIGURE 5A SLIDE 5A

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1. Hayakawa, S.I. Language In Action. Harcourt, Brace and

Company. New York. 1939
2. Byrd, F.E. Germain George L . P r a c t i c a l Loss Cont'rol
Leadership. Institute Pub1 ishing. Loganville, CA 1987.
3. Shank, Roger. The C r e a t i v e A t t i t u d e . MacMillan Publishing
Company. New York. 1988
4. Roscoe, Stanley v Aviation Psychology
The Iowa S t a t e University Press Ames. Iowa. 1989. P168.
5. Clancy, Tom. Cardnel o f the Kremlin.
6. Redondi, Pietro. G a l i l e o Heretic. Translated by Rosenthal
Raymond. Princeton University Press. 1987. Princeton.
New J e r s e y . P7.
7. Kletz, Trevor, A . . An Engineers View of Human Error.
I n s t i t u t e of Chemical Engineers. Rugby, UK. 1985
8. Anderson, Anthony. Computer Pioneer and Much Much More
(Book Review) New S c i e n t i s t . 3, June 1989.

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