Todd Conklin - Pre-Accident Investigations

Pre-Accident Investigations

To everyone who has ever asked how instead of why.

An Introduction to Organizational Safety

TODD CONKLIN

Los Alamos National Laboratory, USA

ASHGATE

Todd Conklin 2012

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without the prior permission of the publisher.

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Ashgate Publishing Limited

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Ashgate Publishing Company

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Todd Conklin has asserted his moral right under the Copyright, Designs and Patents Act, 1988, to be identified as the author of this work.

British Library Cataloguing in Publication Data

Conklin, Todd.

Pre-accident investigations : an introduction to

organizational safety.

1. Industrial safety.

I. Title

658.38-dc23

ISBN: 978-1-4094-4783-2 (hbk)
ISBN: 978-1-4094-4782-5 (pbk)
ISBN: 978-1-4094-4784-9 (ebk-PDF)
ISBN: 978-1-4094-8354-0 (ebk-ePUB)

Library of Congress Cataloging-in-Publication Data

Conklin, Todd.

Pre-accident investigations : an introduction to organizational safety / by Todd Conklin.

p. cm.

Includes bibliographical references and index.

ISBN 978-1-4094-4783-2 (hardback) -- ISBN 978-1-4094-4782-5 (pbk) -

ISBN 978-1-4094-4784-9 (ebook) 1. Industrial safety. I. Title.

T55.C645 2012

363.1065--dc23

2012004878

Printed and bound in Great Britain by the MPG Books Group, UK

Lets start with a story. Humans have an unusually strong bias towards learning through storytelling. I intend to use this same bias to begin this book. In many ways, this story covers everything that we will discuss in this book: the presence of normal operational information in every event; the belief that had we had access to the right knowledge before a failure happened we would have most certainly avoided the failure; the clear absence of failure identification before the failure started. Read this story, and think about how these ideas could apply to your organization. After all, with a couple of little changes, this story could be your organizations story.

A colleague of mine who is a noted high explosive researcher told me this story. In many ways, this story represents the central theme of this book. By retelling this story to you, I am both setting the stage, and engaging your experience in order to make the ideas and concepts more successful and practical for you.

In the history of studying high explosives, an important expert and early father of high explosive research and safety learned a critical lesson. This expert had done hundreds of high risk, highly technical experiments with all sorts of things that blow up. With all this experience, our expert not only became technically famous, but he also became an expert in how to perform this type of work safely.

This expert knew that every time an experiment went wrong, a line of fellow researchers would be at his office door the next morning wanting to tell him why they thought the failed experiment had failed. Sometimes the line went all the way down the hall. Each researcher in this line had a thoughtful idea or two on what went wrong, and how they could help prevent this problem from happening the next time an experiment was to be completed.

Every failure was followed by a formal technical meeting to discuss what happened in the failure. The researcher noted that his fellow scientists had a particularly strong need to have some type of post-mortem discussion about the failure after the failure. Almost like a cleansing ritual. These discussions were always intriguing. Many times the information volunteered during these informal post-mortems would have made a difference to the overall success of the failed experiment. These researchers all seemed to have some pretty clear ideas and observations.

This expert thought, If all this knowledge exists after a failurecould at least some of it exist before a failure? He realized that though some information was clearly only available in retrospect, some must be available before the next experiment was to be fired. Knowing this information before an experiment is done seemed like a very good idea. In fact, responding to this information before the failure happened would be much more efficient and effective, cheaper and faster, and much better for the future of high explosive science.

And thats the moment when the idea of a premortem for high explosive experimentation was born. It is being the Crime Scene Investigator before the crime, and identifying the possible hows before the event.

Having a premortem meeting, a meeting where you ask smart, experienced people what could go wrong before it does go wrong, provides a new set of data about a failure that has yet to happen. Knowing this new information allowed the researchers to avoid a whole series of problems. It was cheap, quick, simple, easy, and most importantly 100 percent effective for the potential failures identified.

A pre-accident investigation is exactly the same idea.

You and your organization can learn from this story. This is your guide to leveraging great, untapped knowledge that already exists in your organization. Your job is to prevent the frequency and severity of events in your company. I am convinced that the only way we can prevent events and failure is by learning. There is data to learn before an incident if you ask the right questions, and are willing to look.

Much like our scientist in the story, when things fail where I work we are extraordinarily smart, and can pinpoint exactly why the failure happened and what we should have done differently. Some of that knowledge surely comes in retrospect, but some of that information clearly existed before the failure happened.

There are many stories about knights slaying dragons. The successful knights were sure to investigate their dragons weaknesses before they started their quest. The investigations gave each knight the knowledge to bring the right tools and skill sets to the dragons lair. It was their investigations that laid all the groundwork for their success.