May 1, 2009 | Mark Paradies

Accident at Papermill in UK Kills 1 – A Case for the Corporate Manslaughter Law? – How would you investigate it?

The Plymouth Harold reported that a man was trapped in a paper machine at the Arjo Wiggins Stowford Mill and, after being rescued by two off-duty firefighters who worked at the mill, later died of his injuries after being airlifted to a hospital.

The investigation is underway and no details have been released. But experienced investigators know that the fatality was most likely related to either machine guarding or lock-out/tag-out (or both).

Were work processes followed?

Did management and supervision enforce work rules or did people frequently take shortcuts?

How would you investigate such a serious accident?

If a TapRooT® Investigation was performed, the first step would be to develop a complete SnapCharT® (sequence of events and conditions). The investigator would do this by using evidence from the scene, from interviews of workers, supervisors, and managers, from work paperwork, from autopsy reports, and from any security videos that may have caught the accident on tape.

The information about “what happened” would then be reviewed to identify the accident’s Causal Factors. Causal Factors are problems that, if corrected or removed, would have stopped the accident sequence and prevented the accident from occurring. Ways to identify Causal Factors are taught in all TapRooT® Root Cause Analysis Courses.

Each of the Causal Factors would be analyzed using the Root Cause Tree® to identify the Causal Factor’s root causes.

Once the root causes are identified, the investigator (or investigative team) would then consider each root cause to see if was an isolated occurrence or whether it was a “generic” cause. Generic causes that are more widespread throughout the organization need a different corrective action than root causes that are isolated to a single accident.

Next, the investigative team and the appropriate stakeholders would develop corrective actions using the Corrective Action Helper® Module of the TapRooT® Software (or the new Corrective Action Helper® Book). They might also use the Behavior Change Matrix to develop corrective actions to enforce rules and the SMARTER Matrix to evaluate and refine their corrective actions.

Finally, they would use tools from TapRooT® to present their finding to management to get approval for the effective corrective actions that were developed to prevent the recurrence of the accident.

The TapRooT® Software also has a database to track the progress of corrective action implementation, validation, and verification.

In the UK, management must now be thinking about criminal prosecution – the fairly new Corporate Manslaughter Law. So before they even start the investigation, legal counsel would need to be consulted for their help with the investigation planning and review. In the US, a company may consider doing the investigation at the direction of an attorney (perhaps even an outside council) to establish an attorney-client privilege for the investigation.

These types of accident investigations are emotionally draining because these tragedies don’t have to happen. They could have been prevented by finding and fixing the root causes of the accident BEFORE the accident occurred by applying root cause analysis proactively.

Would you like to know more about performing difficult investigations and finding and fixing the root causes of problems? Then attend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. We hold these courses all over the world. See:

Root Cause Analysis
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