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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 30‑APRIL 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 |