Archives of Personal Papers ex libris Ludwig Benner, Jr.
   - - - - - -Last updated on Thu, Aug 9, 2012
   [Investigation Catalyst Software ] [ Investigation Research Roundtable Site ]   
[ Contact "me" at ludwigbenner.org ]


128

 

 

 

Source

 

 

MINUTES AND REPORTS

 

1982 SPRING MEETING

AMERICAN PETROLEUM INSTITUTE

COMMITTEE ON SAFETY AND FIRE PROTECTION

 

American

Petroleum

Institute

 

WILLIAMS PLAZA HOTEL

TULSA,

OKLAHOMA

 

MARCH 30APRIL 2, 1982



129

 

MINUTES

AMERICAN PETROLEUM INSTITUTE

COMMITTEE ON SAFETY AND FIRE PROTECTION

WEDNESDAY, MARCH 31, 1982

WILLIAMS PLAZA HOTEL

TULSA, OKLAHOMA

 

The general session was convened at 1:30 p.m. by Chairman Kiunick. A film entitled, "The MGM Grand Fire," was shown to all attendees. Produced by the NFPA, the film deals with the activities and behaviors of occupants at the major life loss fire in Las Vegas, Nevada.

 

Commencing at 2:00 p.m., two guest speakers addressed the topic of "Accident Investigation." The speakers and their topics were:

 

(1)                    "Accident Investigation Research"

                        Ludwig Benner, Jr., PE

                        Institute of Safety and Systems  Management Eastern Division

                        University of Southern California

                        Alexandria, Virginia

 

(2)                    "Investigation of Petroleum Related Accidents"

                        Crawford Wiestling

                        Fire Investigator

                        Robins, Zeller, Larson & Kaplan

                        Minneapolis, Minnesota

 

A copy of the presentations and reference sources can be found as Attachments 1 and 2.



ATTACHMENT 1

130

 

TUTORIAL ON ACCIDENT INVESTIGATON

 

PRESENTATION TO THE AMERICAN PETROLEUM INSTITUTE

March 31, 1982

By Ludwig Benner, Jr. PE

Institute of Safety and Systems Management

University of Southern California

 

THE PURPOSE OF MY PRESENTATION IS TO

+  DESCRIBE TO YOU SOME 'SAFETY DEFECTS' I HAVE DISCOVERED IN ACCIDENT INVESTIGATIONS

+   DESCRIBE WAYS YOU CAN OVERCOME THESE PROBLEMS

+   SUGGEST ACTIONS YOU CAN TAKE, IN LIGHT OF MY FINDINGS

IN THIS SHORT TIME, WE CAN ONLY COVER THE TIP OF THIS SAFETY PROBLEM ICEBERG!

(Insert Iceberg)

FIRST:

WE'LL LOOK AT THE PROBLEMS

NEXT, I'LL DESCRIBE MY RESEARCH

THEN WE'LL LOOK AT THE FINDINGS

THEN I'LL SHARE SOME APPLICATIONS AND RESULTS

LASTLY, I'LL OFFER YOU SOME SUGGESTIONS TO HELP AVOID THESE PROBLEMS

ACCIDENT INVESTIGATION PROBLEMS INCLUDE PROBLEMS WITH INVESTIGATION

• OBJECTIVES

• SCOPE

• METHODS

• OUTPUTS, and

• USES

 

TO EXPLAIN THESE PROBLEMS IN A MEANINGFUL WAY, I AM GOING TO HAVE TO TALK ABOUT SAFETY THEORY, TOO. BY THEORY, I MEAN:

           'A SYSTEM OF ASSUMPTIONS, ACCEPTED PRINCIPLES AND RULES OF  PROCEDURE DEVISED             TO ANALYZE, PREDICT OR OTHERWISE EXPLAIN THE NATURE AND BEHAVIOR OF PHENOMENA.'

ACCIDENTS ARE THE PHENOMENA WE WANT TO EXPLAIN.

LET'S BEGIN BY ASSUMING YOU AND I ARE ACCIDENT INVESTIGATORS. YOU ARE ORDERED TO JOIN ME IN AN INVESTIGATION OF THIS ACCIDENTAL EXPLOSION. WHY ARE WE INVESTIGATING THE ACCIDENT?

-      WHAT SHOULD BE THE OBJECTIVE OF OUR INVESTIGATION?

-      WHAT SHOULD WE BE TRYING TO ACCOMPLISH BY INVESTIGATING THE ACCIDENT?

-      IN OTHER WORDS, WHY BOTHER INVESTIGATING THIS ACCIDENT?

 



131

 

IF WE CAN AGREE ON OUR OBJECTIVE, HOW WILL WE MEASURE THE SUCCESS AND WORTH OF OUR INVESTIGATION AND ITS OUTPUTS?

 

* EVEN MORE FUNDAMENTALLY, WHAT SAFETY ASSMUPTIONS AND PRINCIPLES THEORY DO WE USE AS THE BASIS FOR OUR ANSWERS?

 

OR SUPPOSE YOU AND I HAVE TO INVESTIGATE THIS ACCIDENT A PRODUCT LINE RUPTURE AND RELEASE...

WHAT SHOULD BE THE SCOPE OF OUR INVESTIGATION?

 

SAID ANOTHER WAY, WHEN WILL WE SAY THE ACCIDENT BEGINS AND ENDS

 

*  AGAIN, A MORE CRUCIAL QUESTION: WHAT CONCEPTS AND PRINCIPLES ARE THE BASIS FOR OUR ANSWERS?

 

NOW LET'S SHIFT GEARS FOR A MOMENT.

 

  IMAGINE YOU ARE MY BOSS.

 

SOME OF YOUR ORGANIZATIONS OPERATE TRUCKS. ONE OF YOUR TRUCKS IS INVOLVED IN AN ACCIDENT.

 

  WHAT METHODS DO YOU WANT ME USE TO INVESTIGATE THE ACCIDENT FOR YOU?

 

WHAT CHOICES OF METHODS DO WE HAVE AVAILABLE? CAN YOU NAME OUR CHOICES? WHICH METHOD IS THE BEST FOR ME TO USE? WHAT ARE OUR SELECTION CRITERIA? WHY IS ONE METHOD BETTER THAN ANOTHER? WILL THE METHOD YOU TELL ME TO USE LEAD TO OUTPUTS THAT WILL SATISFY YOU?

 

*  AGAIN, WHAT IS THE THEORETICAL BASIS FOR YOUR ANSWER?

 

ONE OF YOUR PLANTS HAS AN ACCIDENTAL FIRE. YOU WANT ME TO INVESTIGATE THIS ACCIDENAL FIRE FOR YOU. AT THE END OF MY INVESTIGATION, BOSS, WHAT WORK PRODUCT DO YOU WANT ME TO DELIVER TO YOU? A COMPLETED FORM? A NARRATIVE REPORT? RECOMMENDATIONS? MODELS?

WHAT ARE YOUR SPECIFICATIONS FOR MY WORK PRODUCTS? WHERE DO I FIND THEM?

WHY DO YOU WANT ME TO INVESTIGATE WHEN YOUR INSUROR, THE FIRE MARSHAL, POLICE, CORONER OR OTHERS WILL ALSO BE PREPARING REPORTS AFTER THEIR INVESTIGATION?

WHAT DATA SHOULD I INCLUDE IN MY REPORT? WHY?

HOW DO YOU JUDGE THE QUALITY OF MY WORK? WHERE DO I FIND YOUR QUALITY CONTROL STANDARDS?

* ONCE AGAIN, WHAT IS THE THEORETICAL BASIS FOR YOUR SPECIFICATIONS??

 



132

AFTER YOU HAVE MY DELIVERABLES, HOW WILL THEY BE USED?

     WHICH REPORT ‑ THE FIRE MARSHAL'S, INSURANCE COMPANY'S OR MINE ‑ WILL HELP YOU UNDERSTAND THE ACCIDENT BETTER? WRY?

     WHY ARE THERE STILL SOME PEOPLE WHO WILL COMPLAIN THAT THEY NEED 'BETTER DATA' FOR ANALYSIS?

     WHAT EXACTLY IS WRONG WITH OUR DATA, AND HOW CAN WE DECIDE WHAT ADDED DATA WOULD BE WORTH GETTING?

*    ONCE AGAIN, WHAT CONCEPTS ARE BEHIND OUR CRITERIA FOR THESE ANSWERS, AND WHERE DO THEY COME FROM?

LOTS OF QUESTIONS!!!!! ARE THERE REALLY ANSWERS??

I CAN ASSURE YOU THESE ARE NOT JUST RHETORICAL QUESTIONS. THEY ARE REAL TO EVERY THOUGHTFUL INVESTIGATOR. AND THE ANSWERS ARE RARELY TAUGHT IN ANY COURSES I HAVE SEEN!

THEY HAVE TO BE ANSWERED, THOUGH ‑ BY EVERY INVESTIGATOR IN EVERY NEW ACCIDENT INVESTIGATION.

WHAT WE MUST RECOGNIZE IS THAT ALL INVESTIGATORS RESOLVE THESE QUESTIONS IN THEIR OWN WAY BY DOING THE INVESTIGATION THE WAY THEY THINK BEST.

SO WHAT, YOU ASK?

IN THE ABSENCE OF SPECIFIC GUIDANCE, INVESTIGATORS ARE FORCED TO USE PERSONALIZED

METHODOLOGIES   PERSONALIZED METHODOLOGIES RESULT IN PERSONALIZED ACCIDENT DATA.

THINK ABOUT THE EFFECTS OF SUCH EFFORTS ON:

        THE NATURE OF YOUR REPORTS (INVESTIGATOR'S CONCLUSIONS)

        YOUR REPORT CONTENTS (REPRODUCIBLE  OUTPUTS)

        YOUR ATTEMPTS TO CONTROL QUALITY (QUALITY CONTROL)

     YOUR ABILITY TO LINK INVESTIGATION OUTPUTS TO PREDICTED SAFETY PERFORMANCE DERIVED FROM SAFETY ANALYSES (LINKAGE)

GOING BEYOND THE EFFECTS ON YOUR FUNCTIONS, CONSIDER THE RAMIFICATIONS OF SHAKY INVESTIGATIVE OUTPUTS ON

*    YOUR FIRM'S AND OTHERS' SAFETY POLICIES ‑ (REVOKING LICENSES FOR ACCIDENTS??)

*    YOUR FIRM'S, YOUR INDUSTRY'S AND OTHERS' SAFETY PROGRAM STRATEGIES AND TACTICS (FIX SIMPLISTIC CAUSES, WAIT FOR SUFFICIENT DATA?)

*    YOUR EMPLOYEES' AND THE PUBLIC'S OPINIONS ABOUT THE ADEQUACY OF SAFETY LEVELS (SCOPE OF INVESTIGATION INCLUDE TRACKING INJURY?)

*              ON SAFETY RESEACH EFFORTS THAT USE THE DATA (INCLUDING FLAWED DATA?)

*    AND, IN PRACTICAL $, ON LITIGATION STEMMING FROM AN ACCIDENT! (WINNING YOUR CASES?)



133

 

IN MY PERSONAL WORK AT PPG, AIR PRODUCTS, AND THE SAFETY BOARD, AND IN MY CLASSES AT USC, I HAVE BEEN CONFRONTED BY EVERY ONE OF THESE ISSUES AT ONE TIME OR ANOTHER. ALSO, I OBSERVED DIFFERING INVESTIGATIVE METHODOLOGIES BEING USED IN EACH FIELD ‑TRANSPORTATION, WORKPLACE, CONSUMER PRODUCT, DRUG AND OTHRS.

   SOME ACCIDENTS HAD SUCH DESTRUCTIVE POTENTIAL THAT I WOULDN'T DARE RELY ON TREND ANALYSES OR STATISTICAL INFERENCE TO IDENTIFY HAZARDOUS MATERIALS SAFETY PROBLEMS. WE COULDN'T AFFORD THAT FIRST BIG ONE!!

   SOME OF THE ACCIDENTS INVOLVED PEOPLE I KNEW PERSONALLY, SO I WANTED TO USE THE BEST METHODS I COULD FIND.

   I OPERATED IN A 'FISHBOWL ENVIRONMENT, SO I HAD A PRACTICAL NEED TO ANSWER THESE QUESTIONS CONSISTENTLY TO WITHSTAND PUBLIC SCRUTINY.

                                                                                                                                                           I HAD TO DEAL WITH EACH ACCIDENT AS I FOUND IT, AND USUALLY I HAD TROUBLE

RECONCILING WHAT OTHER INVESTIGATORS WERE CONCLUDING WITH WHAT I WAS SEEING

   LASTLY, I HAD REAL PROBLEMS TRYING TO LINK MY INVESTIGATIVE RESULTS TO THE OBJECTIVES OF REGULATIONS, OR TO THE ANALYSES THAT LED TO THE SAFEGUARDS OR PROCEDURES BEFORE ACCIDENTS.

SO I STARTED WATCHING, LISTENING, STUDYING, ANALYZING, EXPERIMENTING, ANALYZING THE RESULTS AND TRYING AGAIN AS I INVESTIGATED ACCIDENTS.

     EACH NEW INVESTIGATION GAVE ME ANOTHER CHANCE TO TEST MY FINDINGS AND IMPROVE THEM.

I AM GRATIFIED TO BE ABLE TO REPORT I FOUND OUT SOME THINGS THAT REALLY HELPED ME.

WHAT DID I FIND???

FIRST, I FOUND A GREAT DISPARITY OF VIEWS AMONG INVESTIGATORS AND THEIR BOSSES. I DISCOVERED ‑

‑ 5 DIFFERING PERCEPTIONS OF THE NATURE OF THE ACCIDENT PHENOMENON

‑ 44 DIFFERING REASONS FOR INVESTIGATING ACCIDENTS,

‑ 7 DIFFERENT ACCIDENT INVESTIGATION PROCESSES,

‑ 6 DIFFERENT METHODOLOGIES, AND

‑ 3 DIFFERING TYPES OF DELIVERABLES

 

+ A COMPLETE LACK OF AGREEMENT ABOUT CRITERIA FOR DETERMINING THE BEGINNING AND END OF THE ACCIDENT, AND THUS THE MATTERS REPORTED!



134

IS IT ANY WONDER WE HAVE QUESTIONS, CONTROVERSY AND LOTS OF LITIGATION AFTER ACCIDENTS?

PROBABLY MOST IMPORTANTLY, I HAVE FOUND 5 PERCEPTIONS ABOUT WHAT AN ACCIDENT IS. THEY ARE REPORTED IN SEVERAL RECENT PAPERS, AND I WON'T GET INTO A LOT OF DETAIL. BRIEFLY, THEY INCLUDE THE

• SINGLE EVENT

• CHAIN OF EVENTS

• FACTORIAL

• BRANCHED EVENTS CHAIN

• MULTILINEAR EVENTS SEQUENCES PERCEPTIONS.

 

UNDERSTANDING THESE DIFFERENCES HAS HELPED ME TREMENDOUSLY IN UNDERSTANDING WHY WE HAVE SO MANY DIFFERENCES OF OPINION ABOUT OTHER SAFETY MATTERS, TOO.

 

REALIZING ALL THIS, COULD I DEVELOP SOMETHING BETTER? WELL, THAT'S WHAT MY EXPERIMENTATION AIMED TO DO.

 

I USED THE FINDINGS TO

-     SYNTHESIZE A PERCEPTUAL FRAMEWORK THAT WOULD ALLOW ME TO RESOLVE ALL THE QUESTIONS IN THE INVESTIGATION PUZZLE AND TIE INVESTIGATIONS TO PREDICTIVE ANALYSES,

-      ISOLATE PRINCIPLES THAT HELPED ME IMPROVE MY INVESTIGATIONS,

-      DEVELOP A METHODOLOGY THAT WOULD GIVE ME REPRODUCIBLE OUTPUTS, AND

    DEVISE WAYS TO SIMULATE INVESTIGATIONS SO THE METHODS COULD BE TAUGHT.

 

LET ME SHARE THE FRAMEWORK AND PRINCIPLES WITH YOU BRIEFLY.

 

I AN GOING TO GET THEORETICAL WITH YOU FOR A MOMENT. PLEASE TURN TO THE HANDOUT THAT HAS THE MUSICAL SCORE ON IT. WHILE YOU HAVE THE HANDOUT, I AN GOING TO PLAY A TAPE FOR YOU. I HAVE RECORDED THIS PART OF MY PRESENTATION FOR REASONS THAT WILL BE OBVIOUS IN JUST A MOMENT.

 

(RUN TAPE ‑ REFER TO HANDOUT)

 

(CONTINUE WITH PRESENTATION)

 



135

 

WITHIN THIS FRAMEWORK, 4 KEY PRINCIPLES HAVE BEEN IDENTIFIED:

 

1.      THINK EVENTS BUILDING BLOCKS

‑ THAT IS, BREAK DOWN YOUR ACCIDENT INFORMATION INTO SINGLE ACTIONS BY EACH ACTOR, TO FASHION BASIC BUILDING BLOCKS CALLED 'EVENTS'.

 

2.      THINK EVENTS EQJNCES

‑ THAT MEANS YOU ASSEMBLE THE BUILDING BLOCKS INTO SEQUENTIAL STRINGS OF EVENTS FOR EACH ACTOR YOU ARE TRACKING DURING THE ACCIDENT, BOTH ANIMATE AND INANIMATE.

 

3.      MAKE MENTAL MOVIES

‑ THAT MEANS YOU TRY TO ORGANIZE THE STRINGS OF EVENTS INTO 'FRAMES' OF A MENTAL

MOVIE THAT SHOWS THE INTERACTIONS AMONG THE ACTORS DURING THE ACCIDENT.

 

4. ESTABLISH RELATIVE EVENTS TIMING

‑ THAT MEANS YOU HAVE TO SHOW THE EFFECTS OF TIMING ON EACH EVENTS SET REPORTED IN YOUR DELIVERABLES.

 

FAILURE TO OBSERVE THIS LAST PRINCIPLE IS A FATAL SAFETY DEFECT IN ALMOST EVERY ACCIDENT INVESTIGATION WORK PRODUCT I HAVE REVIEWED IN THE PAST 12 YEARS EXECPT FOR A FEW MAJOR AIRCRAFT ACCIDENT AND HAZARDOUS MATERIALS ACCIDENT CASES.

 

TO APPLY THESE PRINCIPLES, AN INVESTIGATIVE METHODOLOGY HAS BEEN SYNTHESIZED, BASED ON GRAPHIC MODELING OF ACCIDENT EVENTS.

 

THE 4 KEY ELEMENTS OF THAT SYSTEM ARE

 

A TIME LINE TO DISCIPLINE THE TESTING OF RELATIONSHIPS AMONG EVENTS IDENTIFIED DURING AN INVESTIGATION,

AN EVENTS MATRIX SYSTEM TO DISPLAY AND SEQUENTIALLY ARRAY THE EVENTS BUILDING BLOCKS INTO A MODEL OF THE ACCIDENT,

AN ARROW CONVENTION TO DISPLAY THE AGREED‑UPON PROCEED/FOLLOW LOGIC OF THE EVENTS RELATIONSHIPS DURING THE ACCIDENT, AND

A COUNTERMEASURE TAB SYSTEM TO INDICATE WHERE THE FLOW OF EVENTS MIGHT BE CONTROLLED BY SOME DESIGN MODIFICATION, SAFEGUARD, PROCEDURE OR WARNING.

 

THIS SLIDE SHOWS THE GENERAL CONFIGURATION OF THE MULTILINEAR EVENTS SEQUENCING MATRIX, WITHOUT COUNTERMEASURE TABS.

 

HERE IS AN EARLY, VERY SIMPLIFIED WORKING EXAMPLE OF THE MATRIX TECHNIQUE, DISPLAYING A GENERALIZED MODEL OF ACCIDENT EVENTS SEQUENCES, WITH COUNTERMEASURES INDICATED.



136

 

SIMULATIONS OF THIS INVESTIGATIVE PROCESS HAVE BEEN DEVELOPED SO IT CAN BE TAUGHT. THE SIMULATIONS INCLUDE

     DEVELOPMENT OF AN INVESTIGATIVE PLAN THAT TAKES INTO CONSIDERATION THE INTERESTS OF ALL PARTIES WITH A STAKE IN HE INVESTIGATION,

     WAYS TO USE THE PRINCIPLES TO PRODUCE VASTLY IMPROVED WITNESS INTERVIEWS,

     DEVELOPMENT OF PLANS FOR TESTING DEBRIS AFTER AN ACCIDENT TO AVOID WASTING A LOT OF DATA, TIME AND MONEY, AND

     HANDS ON EXPERIENCE WITH WAYS TO ORGANIZE ACCIDENT DATA SO IT IS MORE EFFICIENT, CONVINCING AND REPRODUCIBLE.

 

IF YOU DESIRE MORE DETAIL, I WOULD BE HAPPY TO SEND YOU REFERENCES. (See attached.)

 

DOES IT WORK? YES, WITHOUT QUALIFICATION.

 

‑DURING ACCIDENT INVESTIGATIONS, THE MES METHODOLOGY WAS USED TO DEVELOP MODELS OF FIREFIGHTERS' EMERGENCY DECISION MAKING PROCESS AND OF HAZARDOUS MATERIAL ACCIDENT BEHAVIOR.

 

‑DURING SUBSEQUENT INVESTIGATIONS, THESE MODELS WERE TESTED AND REFINED, PROVIDING GUIDANCE TO THE INVESTIGATORS ABOUT THE ACCIDENT DATA THEY SHOULD COLLECT AND REPORT.

 

THE 1974 MODEL SHOWN JUST A MOMENT AGO WAS REFINED SUBSTANTIALLY.

 

‑YOU MAY HAVE HEARD OF THE D.E.C.I.D.E. PROCESS BEING USED INCREASINGLY TO TRAIN EMERGENCY RESPONSE PEOPLE FOR HAZARDOUS MATERIALS EMERGENCIES. IT WAS DEVELOPED WITH THESE MULTILINEAR EVENTS SEQUENCES OR MES TECHNIQUES. D.E.C.I.D.E. IS CHANGING THE WAY THESE PERSONNEL ARE BEING PROGRAMMED TO RESPOND TO ‑ AND ANALYZE ‑ THE HAZARDOUS MATERIALS ACCIDENT PROBLEMS.

 

SO WHAT DOES THIS ALL MEAN TO YOU? SEVERAL THINGS.

 

1. NEW TECHNOLOGY HAS BEEN DEVELOPED TO IMPROVE ACCIDENT INVESTIGATION.

 

2. IF YOU ARE USING OBSOLETE INVESTIGATIVE TECHNOLOGY, YOUR INVESTIGATIVE WORK

PRODUCTS ARE NOT SERVING YOU AS WELL AS THEY SHOULD AND COULD.

 

3. IF YOUR WORK IS BASED ON OBSOLETE TECHNOLOGY, AND SOMEONE USES THIS

TECHNOLOGY AGAINST YOU, YOU'RE GOING TO ENCOUNTER PROBLEMS IN THESE AREAS!

 



137

 

WHAT SHOULD YOU DO? AT LEAST 5 THINGS.

 

1.   REEXAMINE YOUR PERCEPTIONS OF THE ACCIDENT PHENOMENON, AND WORK UP SOME KIND OF REPORT WITHIN YOUR SAFETY ORGANIZATION SO AT LEAST ALL YOUR PEOPLE WILL EXHIBIT CONSISTENT VIEWPOINTS AND RESULTANT ACTIONS.

 

2.   REEXAMINE THE INVESTIGATIVE METHODOLOGIES YOUR GROUP USES, AND THE VALUE OF THE OUPUTS RESULTING FROM THEIR USE, SO YOU CAN START MOVING TOWARD THE ONE THAT SERVES YOU BEST IN YOUR ORGANIZATION.

 

3.   ENLIST YOUR INVESTIGATORS TO HELP YOU FIND THE BEST INVESTIGATIVE METHODOLOGY, BECAUSE THEY CAN TEST DIFFERENT METHODS QUICKLY AND GIVE YOU USEFUL FEEDBACK.

 

4.   BRING THE DIFFERING PERCEPTIONS OF THE ACCIDENT PHENOMENON TO THE ATTENTION OF OTHERS IN YOUR ORGANIZATION, AND PREPARE THEM FOR THE POSSIBLE CHANGES YOU WILL BE INTRODUCING IN YOUR SAFETY PROGRAMS IF YOU MOVE TOWARD A SINGLE PERCEPTION.

 

5.   RECOGNIZE THE DEFICIENCIES IN EXISTING ACCIDENT INVESTIGATION DATA, AND MAKE SURE THAT PEOPLE WHO USE YOUR OUPUTS FOR SECONDARY ANALYSIS KNOW AND ACKNOWLEDGE THE PROBLEMS IN ANY CONCLUSIONS THEY DRAW FROM PAST ACCIDENT REPORTS.

 

FINALLY, I'D LIKE TO PLANT A SEED.

 

    ANY ACCIDENT WORTH INVESTIGATING IS WORTH INVESTIGATION COMPLETELY. IF YOU ACCEPT THIS VIEW, I'D LIKE TO INVITE YOU TO WORK WITH ME TOWARD AN IDEAL ‑

 

THE IDEAL:

 

ONE ACCIDENT REPORT TO SERVE ALL USERS

 

end

 



138

TUTORIAL ON ACCIDENT

INVESTIGATION

 

PRESENTATION TO THE AMERICAN PETROLEUM

INSTITUTE

March 31, 1982

By Ludwig Benner, Jr. PE

Institute of Safety and Systems Management

University of Southern California

 

RELATED REFERENCES

 

I, SAFETY CONCEPTS

 

  1. RISK, RESPONSIBILITY AND RESEARCH                                                                       12 pages

Presentation to American Chemical Society by Ludwig Benner, Jr. (1975)(32 references)

 

Examines changing societal demands for avoiding man‑made catastrophic chemical safety surprises, and for better predictive methodologies to discover, evaluate and control chemical risks. It describes semantic, perceptual and methodological obstacles to meeting these demands, defines risk control and measurement research needs and suggests a new role for professionals in the chemical field. Helpful for understanding obstacles to "safety" improvements.

 

2. GENERATING HYPOTHESES TO EXPLAIN ACCIDENTS AND OTHER RARE EVENTS      4 pages

Guest Editorial in Journal of Safety Research by Ludwig Benner, Jr. (1978) (4 references)

 

Helpful for recognizing that origins for criteria used to evaluate safety hypotheses underlying safety research need reexamination.

 

3. CRASH THEORIES AND THEIR IMPLICATIONS FOR ACCIDENT RESEARCH                      10 pages

Paper published by the American Association For Automotive Medicine, by Ludwig Benner, Jr. (1979) (14 references)

 

Five different perceptions of the nature of the accident phenomenon are introduced in this paper. Resultant investigative, data and methodological traps and their implications for safety research are outlined. Researchers are called on to reexamine and specify which perception drives their work products. Useful for exploring the reasons why evaluations

  of safety countermeasures are so difficult.

 

  4. UNDERSTANDING ACCIDENTS: A CASE FOR NEW PERCEPTIONS AND METHODOLOGIES

                                                                                                                                             18 pages

  SPECIAL "MUSICAL SCORE" ILLUSTRATION                                                                         1 page

Paper for the Society of Automotive Engineers by Ludwig Benner, Jr. (1980) (42 references)

in 1980 SAE TRANSACTIONS

 

An extensive discussion of serious problems with methodologies used in accident research and investigations, including an allegation that most accident data is fatally flawed. Suggests an approach to resolve these problems. Includes extensive appendices. Useful for identifying specific conceptual safety problems confronting safety practitioners. The "musical score" sheet displays analogies between musical scores and multilinear events sequences (MES) accident events‑charting methods.


139

5. EVALUATING DANGEROUS GOODS EMERGENCY RESPONSE WITH TIME/LOSS ANALYSES

                                                                                                                                            8 pages

Presentation at 6th International Symposium‑Packaging and Transportation of Radioactive Materials, Berlin(West), Federal Republic of Germany by E.T. Driver (1980) Also in FIRE JOURNAL July 1981.

 

Provides a general method for tracking changes in loss over time as a basis for evaluating performance of safeguards and safety procedures, with examples illustrating method. Analytical, preplanning and regulatory implications of method are discussed. Helpful for exploring ways to link predicted safety performance to actual performance, and establishing criteria to evaluate predictive safety analysis methodologies.

 

II. ACCIDENT INVESTIGATION

 

1. ACCIDENT INVESTIGATION: MULTILII4EAR EVENTS SEQUENCING METHODS              8 pages

A research paper published in the Journal of Safety Research by Ludwig Benner, Jr.(1975) (13 references)

 

Special list of 110 accident investigation references related to paper: 7 pages (Available from author)

 

Makes plea for generally accepted approaches and analysis methods that will result in complete, reproducible, conceptually consistent and easily communicated explanations of accidents. Suggests generalized explanation of accident phenomenon, and "multilinear events sequences" (MES) technique for displaying accident data. Helps identify criteria for evaluating accident investigation work products.

 

  2. ACCIDENT THEORY AND ACCIDENT INVESTIGATION                                                  7  pages

Research paper presented Society of Air Safety Investigators by Ludwig Benner, Jr.(1975) in

1975 ISASI ANNUAL CONFERENCE PROCEEDINGS (22 references)

 

Introduces accident theory problems behind investigative problems. Suggests that accidents be viewed as a transformation process by which homeostatic activity is interrupted with accompanying harm, and describes procedural steps for charting accident events into multilinear events sequences (MES) accident process chart display. Proposes tests for display entries. Helps identify need for disciplined investigative approaches.

 

3. FOUR ACCIDENT INVESTIGATION GAMES: SIMULATIONS OF THE ACCIDENT INVESTIGATION PROCESS 60 pages

Four games developed illustrate accident investigation processes by Ludwig Benner, Jr. (1979) Published by LUFRED INDUSTRIES, INC. Oakton, Va. 22124

 

Games address planning investigation in face of divergent interests; witness interviews; debris test plans; and investigative data organization and evaluation. Contains descriptions of MES outputs, rules for recording accident events, investigative principles. Convenient way to learn MES methods and grasp significance of new methodology..

 

4. FOUR ACCIDENT INVESTIGATION GANES:INSTRUCTOR'S MANUAL                                98 pages

A full explanation of the DIA‑GRAMS system of accident investigation by Ludwig Benner, Jr. (1979) Published by LUFRED INDUSTRIES, INC. Oakton, Va. 22124

 

Contains complete instructions for conducting the four simulations of the accident investigation process, with examples of answers, charts, investigative work products, and a completed 10' MES chart. 9 appendices fully illustrate points made, including annotated references.


140

 

5. FIVE ACCIDENT PERCEPTIONS:THEIR IMPLICATIONS FOR ACCIDENT INVESTIGATORS 9 pages

An interpretive paper by Ludwig Benner, Jr. (1980) (36 references) in HAZARD PREVENTION 16:11, and in PROFESSIONAL SAFETY 27:2

 

Presents strengths and weaknesses of existing accident investigation processes resulting from differing perceptions of the accident phenomenon. Adverse consequences cited include

- individualized investigative methodologies,

- difficulty in linking investigative outputs to predictive safety estimates, and

- career ramifications for  investigators..

Useful for exploring quality criteria for investigative programs, work products. initiatives.

 

III. PUBLICATIONS ABOUT APPLICATIONS

 

1.   D.E.CI.D.E. IN HAZARDOUS MATERIALS EMERGENCIES                                               8 pages

 

A landmark research paper in the fire service field, by Ludwig Benner, Jr.(1975) in FIRE JOURNAL 69:4

Redefines the purpose of emergency response actions in terms of outcomes achieved, models the nature of an emergency, and casts the management of an emergency into a decision process model. Contains emergency and hazardous material behavior models devised from accident investigations.

 

2. MANAGING HAZARDOUS MATERIALS EMERGENCIES: THE M.A.P.S. METHOD

 

A 3‑module audio‑visual slide/tape set for simulating hazardous materials emergencies for planning and tactical exercises, by Michael S. Hildebrand and Ludwig Benner, Jr., (1981) published by the Robert J. Brady Co., Bowie, MD.

 

3.  Hildebrand, M.S., NTSB MAPS CAN HELP WITH HAZARDOUS MATERIAL  EMERGENCIES.

 

Describes procedure for using NTSB maps for hazardous materials planning and simulations, by M. S. Hildebrand, in FIRE CHIEF magazine

 

4.  PHOSPHORUS TRICHLORIDE RELEASE IN BOSTON AND MAINE YARD 8, SOMERVILLE MA., APRIL 4,  1980.

 

This is an official government report with an events chart of the handling of an accidental hazardous material spill, by National Transportation Safety Board, Special Investigation Report HZM 81-1

 

 

 

 

End