November 18, 2009
Accident Investigation – A case study

As the CAW national health and safety coordinator for VIA Rail it is a part of my job to review the minutes of all the local work place
committees across Canada.  These minutes include the results of accident investigations that were conducted by the committee.  
Often I find that result of the investigation leads to a recommendation to tell the injured worker to be more careful. While this may
seem like common sense, in fact it is seriously misleading in most cases, and indicates a lack of knowledge and/or thoroughness on
the part of the investigators.  The view that most accidents are caused by the unsafe act of an individual is now outdated as it
ignores the rest of the system of work, and fails to get to the root of the problem.

“Remember not to jump off trucks”
This accident investigator was investigating an injury accident. He interviewed the Branch Manager for a small rental company, who
fell off the back of his truck and suffered a scalp injury that required medical aid.  Following his training the investigator has made a
list of each of the actors in this drama and now he wants to get each of their stories.  He is going to ask about:

  • the truck;
  • the door;
  • the wash pump;
  • the wash hose;
  • the wash wand;
  • the telephone;
  • the door chain;
  • the tailgate where the wand was stuck.

He also has some questions about the after accident response by the boss and maybe some questions about the safety program.  
The following is a transcript of the investigator's interview with the injured worker:

Could you please tell me exactly what happened?  Start at the beginning, perhaps from when you arrived at work in the morning.
Well okay.  I got to work about 8 o'clock.  I came in the back and checked the yard.  I came in and made coffee and did some
paperwork.  There was one customer that came in for a rental.  I phoned in the morning report and did some cleaning of stuff.  
John, the shop guy was taking the day off because we worked the weekend.  Things were pretty quiet so I decided to wash the
truck.  There was quite a mess in the back of the truck from tossing the tire chains in there.  I drove the truck up to the door but I
didn't bring it in because of the mud.  I washed the front half but the hose on the pressure washer wouldn't reach all the way
around so I turned the truck around to wash the back.  I climbed up into the box to clean that.  While I was washing the box, I
heard the phone ringing.  I stuck the wash wand in the tailgate and turned to jump off the truck.  The garage door wasn't open
very high and I hit my head on it and my feet slipped on the floor so I kind of fell backwards.  I was lying there trying to catch my
breath when I saw the door coming down.  I must have jostled the chain out of the hook.  I managed to get my arms up and
stopped the door without getting hurt.  In fact I was kind of congratulating myself because I hadn't got too hurt hitting the door or
falling down or with the door coming down.  I heard a change in the sound of the wash gun and saw that the door had hit the hose
and knocked the wand loose.  It started waving around and hitting me.  I couldn't protect myself too good because I was holding
up the heavy door.  The wand caught me a couple of good ones before I could crawl away under the door.  I got up and ran to the
phone but it quit ringing just as I got to it.  I cleaned myself up and phoned the boss and then went down to the hospital to get
some stitches.

Q. Anything else. (Long wait to force a response)
A. No, that's about it.

Q. (Just waits)
A. I know we aren't supposed to jump off the back of trucks but I had to get that phone.

Q. That's all right we are just trying to figure out exactly what happened to keep it from happening again.  We are not blaming
anyone.  Can I ask you about a few of the things you mentioned?
A. Sure but that is pretty well the whole story.

Q. What kind of a truck was it?
A. It's a pretty new Ford extended cab.

Q. How high is the tailgate off the ground?
A. Well, it's a four-wheel drive so it is pretty high and when it is backed up to the door there is a pretty good slope so it is even
higher.  It's about up to my chest and I had to climb up on it.

Q. Wouldn't it have been easier to wash if the truck was parked out where it was level or the back was downhill?
A. Yeah. But the hose won't reach.

Q. Can you get a longer hose?
A. Oh. I have an extension but I don't use it because the fittings are really stiff and hard to get on.

Q. How long has it been bad and does anyone know about it?
A. I quit using it last year.  I think I mentioned it to someone.  Well maybe not.  The shop guy never uses it because he just washes
inside the shop.  I probably would have got it fixed if he had complained.

Q. Okay so the truck was up to the door because of the short hose.  Is there a small door as well as the big one?
A. Yeah.  There is a man door but I used the big one because the hose had to go out the big one.

Q. How high was the door open?
A. Just as high as I could lift it.  I didn't take it up any higher with the chain because it doesn't work very good and it is kind of hard
to pull up.  I didn't need it very high because I wasn't going to bring the truck in.

Q. Why is the door so hard to pull up?
A. We had a break in a while back and they got in by jacking up the door.  It kind of wrecked it and I don't think I quite got the
springs adjusted right.

Q. You fixed it yourself!
A. Yeah.  We don't have any overhead door guys in town and it would cost a lot to get someone from the city.  Hey, you know, I
always tell our guys that there are only two positions for those doors; all the way open or all the way closed.  I started with this
company by backing a truck through the bottom panel of an overhead door that wasn't all the way open.  Guess I should follow my
own advice.

Q. Okay so the door was up high enough to get out but not high enough when you are coming off a truck.  But you could see the
door.  How did you hit it?
A. Well, I suppose I never actually looked.  I was in a hurry to get the phone and I had to stick the wash gun somewhere secure.  
So once I got it wedged I just turned and jumped.

Q. Couldn't you just set it down?  Those things have a shut off.
A. Maybe yours does, but ours doesn't.  We took it off a while back.

Q. Why?
A. When we shut it off the motor would start to smoke and we would pop the breaker.

Q. Isn't there a pressure by-pass on the pump'?
A. Yeah we had it fixed a few times but they never last and the repairs are expensive.  It's easier just to not shut it off.

Q. Okay, so you ran into the door coming off the truck.  You are sure lucky you didn't do yourself some major harm.
A. For sure.  I should have climbed down.  And like I said, I was congratulating myself on my luck when the hose started beating on

Q. You couldn't get away because the door was down on you.  What caused it to fall?
A. I told you.  I hit it with my head.  I can show you the bruise.

Q. Okay but hitting a door shouldn't make it come down.
A. Oh.  I see what you mean.  Well the door is held up by that double hook thing.  It's not too good now since those guys broke in.  
When they jacked up the door it kind of straightened the hook and popped the chain out.  You have to set it in real careful now so it
doesn't slip out.  It isn't a problem when the door is all the way up because you have to pull it down then.  It is only when the chain
is holding the weight of the door that it matters.

Q. Can you get a new hook?
A. I probably could but I can fix it.  That will solve the problem and prevent another accident.  Won't it?

Q. It would help.  Just a few more questions.  Where was the telephone?
A. It is up front in the office.  We have a bell back in the shop so we can hear it ringing.

Q. You have to go from the shop to the office to answer the phone?
A. Yes.  But it isn't a problem usually because I am up front and get the phone.   The shop bell is just in case I am back here.

Q. What would happen if you didn't answer it?
A. If it is a customer I could miss a rental.  If it is the office, I would catch it for not answering.

Q. Isn't there a voicemail or answering machine in case you miss a call?
A. We believe in service.  Customers hate those machines.  We have an answering service with real people to take the calls when
we are out or after hours.

Q. Could they take the calls while you are out washing trucks?
A. Yeah.  I just have to call them and tell them to watch my phone.  That might have made more sense than trying to run for it.

Q. Do you normally run for it or is that a figure of speech?
A. I guess I do actually run when I am back in the shop.  The boss wants it answered before the third ring.  It shows we're sharp
and give quick service.  Then you gotta say the stupid paragraph which takes longer than three more rings.  Did you know I say,
"Good afternoon this is Will Smart divisional manager of Budget Oilfield Rentals, how may I lighten your load."  Yeah really.  "How
may I ighten your load?"  My customers are sick of it.  They have even quit with the wise cracks.  I would like to drop it but if I don't
say it and it is the boss I sure get an earful.  But it is his business so he gets to say how to run it.

Q. Could you put an extension phone in the shop?
A. Do you know how much that would cost?  This is a shop we are talking about.  The wires would all have to be in conduit and then
we would have to find a way to mount it and then some kind of a desk thing for papers.  Then you would still have to run up to the
front to look things up or get the right forms.  No way we could do it.

Q. Okay. A few more things.  You have a safety program.  Does that include inspections?
A. You bet.  We inspect the shop every day and mark a checklist.  We do a hazard assessment every month.  Head office does a
quarterly inspection and we get an auditor through here every year.

Q. Has anyone ever written down on the inspections that the door was hard to open, the chain hook wasn't secure, the wash pump
needs repair, the extension hose was unusable, and the wand trigger was missing?
A. Oh no.  Those aren't really hazards.

Q. Okay.  Just one last thing.  You said you phoned the boss then drove yourself to the hospital.  If your shop man was bleeding
would you tell him to drive himself to the hospital?
A. Of course not.

Q. Is there anyone in town you can call for help?  Any of the neighbouring businesses?
A. Sure we are all good friends.  In fact we have it in our fire emergency evacuation procedures that we can go across the street to
Fred's Trucking and their guys can come here.  They would have driven me.  I just didn't want to bother anyone.

Q. Thank you for your cooperation and your excellent answers.  It will be about a week before I have the written report complete
with my recommendations.  I will see that you get a copy.

An apparently simple accident report saying a man slipped getting off a truck often gets a response like a memo saying "Remember
not to jump off trucks".  An investigation as simple as interviewing the victim can bring to light the underlying problems or root
causes of an accident.

There is always more to a story than is first told.  Thinking of each thing in the story as an actor and getting their story or history is
a tool that can guide the investigator.

An investigation that stops at operator error or wrong behaviour or unsafe acts doesn't give much room for good recommendations.
The investigation must keep going until some of the reasons for the unsafe acts, behaviour or errors are uncovered.  You can't fix
stupid.  Keep investigating until you find something that can be fixed.

By Ken Cameron - National Health & Safety Coordinator, CAW National Council 4000
Article featured in the July-October edition of the CAW Health & Safety Newsletter