What Happened?


‘If it is Predictable, it is Preventable’

CarolinaFireJournal - By Jonathan Olson
By Jonathan Olson
05/12/2016 -

You have just walked out of a stressful meeting with the budget staff when your phone rings. One of your ambulances has been involved in a collision with another motorist. A myriad of things are now going through your mind all focused on one question — what happened?

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Incidents involving vehicle fleets, especially in public safety entities, are going to happen. But as Gordon Graham has been quoted, “if it is predictable, it is preventable.” Prevention to the point of elimination may not be realistic, but are we learning enough about “what happened” to apply it towards avoiding the next like scenario?

Per an April 2014 report from the National Highway Transportation Safety Administration (NHTSA), there are on average 12 ambulance collisions reported per day nationwide. This figure is inclusive of both injury and damage only events. The bigger your fleet is and the more miles it travels, the more likely you are to experience such an event. Most of them don’t make the news. Most of them don’t result in an injury or worse outcome. But all of them involve your personnel and all of them potentially render part of your fleet out-of-service for an unknown amount of time.

But back to the question — do we know what happened? Do we know what caused this event to take place? Do we have the data to show what was happening up to the point of the collision? Are we able to use that data to prevent the next collision — one that has the potential to be more serious than the last collision? We cannot accurately answer this question without a system to gather the necessary information and data and without conducting a thorough investigation using that information.

Law enforcement generally is the agency with jurisdiction when it comes to determining whether there has been a crime committed in the incident. The insurance companies commonly determine fault and liability after a motor vehicle collision. The outcome of these investigations can provide you with some general information towards what happened, but it is often not enough for you to determine exactly why the incident occurred, rather than what the outcome of the incident was.

All incidents that result in damage or injury must be thoroughly investigated by an agency. By thorough, this doesn’t always require the hiring of an external subject matter expert to conduct a forensic level inquiry. For most incidents, an internal investigation can yield the necessary information to provide you with an accurate determination of the why. But you have to have a plan.

The first step in such an approach is developing a process for use by supervisors or administrators at the time of the incident. It’s essential to have a defined and well-trained process for several reasons. First of all, if you are truly intent on using the outcomes of such investigations to drive improvement and enhance safety, they must be done consistently. Without consistency in this process, the personnel that are most often the subject of these reviews — very few events are likely to occur with properly parked and unattended vehicles — are unlikely to have confidence in the process and embrace the results. Only when the results are embraced and seen as valid is change able to occur and prevention improved.

The process must be thorough enough to yield actionable information, yet practical enough that it can be implemented quickly and completed in a timely manner. Data collection should under most circumstances take no more than 30 to 45 minutes once the investigator has arrived on the scene and is in contact with the involved parties. If the investigator is not well trained on the tasks and expectations, confidence in what they are doing by those involved will be questioned.

The first step in developing your process is to define who will be responsible for the initial investigation at a scene and how they will be notified. In most organizations this process should start with whoever the first line supervisor is — as long as they are not involved in the incident themselves. First line supervisors are usually on-duty or available 24 hours a day and can respond quickly to get the process moving in a timely fashion. Notification is an obvious occurrence in some scenarios, however can easily be overlooked in others. Collisions that automatically result in a law enforcement dispatch can’t avoid a notification being made. It is the events that result in minimal damage that are often challenging to get a notification on. The creased step bumper of unknown origin is a commonplace. And while the cost of such events may be minimal, it is a symptom of a bigger problem that unless corrected, will continue to escalate. Confidence in the integrity of your process, and confidence in your staff that the primary objective of investigating incidents large and small is for improvement, and not always discipline, will increase the timeliness and occurrence of proper notifications. Staff must also know how to make such notifications at all times if you are going to achieve the desired outcome.

As previously stated, once the investigator is on the scene, the preliminary process should take no more than 30 to 45 minutes. This assumes of course that the investigator does not have tasks of a higher priority that must be attended to first, like managing the scene you are a part of. For incidents that require both scene management and investigation, it’s beneficial to have two individuals split those responsibilities to allow for the effectiveness and efficiency of each. The investigator needs to strictly adhere to a checklist in order to ensure consistency and thoroughness.

The first item on the checklist is gathering statements from all staff members involved in the incident. Many agencies have some type of on-line or computer based means for collecting such statements, however gathering this information right here and right now is very beneficial. With time, perceptions and beliefs of what happened may change. Hand everyone involved a clipboard with an open ended form to collect their perspective and involvement in the event as soon as possible. Information on this form should include points such as what was the individual’s role at the time of the event —— driver, backer, etc. — where were they physically at when it happened, what were they doing at the time, and then a complete first person written account of what happened.

Once this information collection has been started, the investigator should spend a few minutes with the individual that was in control of the vehicle at the time of the incident. The potential for driver impairment is a reality that we cannot overlook. Whether it is from fatigue or another cause, evaluation of the driver and determination or elimination of reasonable suspicion must be completed early in the process. More often than not, the investigator knows the driver, and knows what their baseline demeanor and affect is. Having a standardized mechanism to both evaluate and document these findings is essential to the credibility of both the process and the organization.

Determining if there is any impairment present, or to what level, may be above the scope of what many organizations train supervisors to do today, however it is a skill set that can be applied not only on the collision scene. There are standard tactics used in the training of law enforcement officers to identify impairment that can be easily applied to other public safety discipline managers and would be a worthwhile investment of that training time. Establishing that there is or is not a reasonable suspicion is an essential but often overlooked step. When something just does not seem right, involving law enforcement to get a second opinion should be standard practice.

The investigator should have a worksheet for information collection to ensure consistency and completeness. They will need to collect the standard information required for any incident documentation, but make sure that items that may not be obvious are also noted. Examples of this would include the time of day, including the ambient light conditions, what was the weather and how the weather altered road conditions, and what safety devices were in use at the time of the event, including both personal restraints and warning devices on the vehicle. Another data point that needs to be noted was how many consecutive hours had the operator of the vehicle been at work. Fatigue can clearly be an impairing factor and without the routine collection of this data from people involved in incidents, your organization cannot begin to establish quantified standards as to how long is too long to safely be at work.

A final consideration during the initial investigation is the collection of photographs. It can be beneficial to have photographs of the driver’s perspective at the time of an incident for further review and training purposes. It’s also of value to capture images of the actual damages that resulted in the incident to better emphasize in training that these are the kind of things we are looking to avoid. Pictures of step bumpers with the actual cost of repair can leave an impact on the folks that operate your vehicles and provide them a perspective that they may otherwise never see. In today’s digital world, this can be done effectively with minimal expense. The process does need to define where the photographs are stored and who has access to them. You don’t want your carefully collected scene photos to end up on a social media site by days end.

Once the scene work is completed and the other documentation has been collected — police reports, etc. The next step is to review all of the information to gather consensus not only on what happened but why. This task should involve not only the original investigator, but other stakeholders in the organization as well. The outcome of this review should answer the following questions:

  1. Was it preventable?
  2. Did it result due to a policy violation?
  3. Did it result due to the absence of training and/or direction?
  4. What action can be taken to prevent a replication of the event?

Prevention can be a very ambiguous term. Anything can theoretically be prevented. The collision would have never happened had the vehicle never left the station. But given that is not an option, we must look at the scenario from all angles to see what could have been done differently which could have resulted in a different outcome. Often times the scenario is as a result of the operator performing in a manner that was not consistent with the expectations of the department. Was the speed too great for conditions? Was there no backer in place as the vehicle was moving in reverse or was there ineffective communications between the driver and the spotter? These situations should result in a reinforcement of expectations to all personnel and often include the necessary coaching or disciplinary action from those with first-hand involvement in the event. The conclusion can also be that such specifics have not been directly addressed through expectations or policy. Or it could be that the collective enforcement of expectations and policy has not resulted in them being adopted as practice across the agency. That being said, not every event that happens for which there is not a rule forbidding it must result in a new policy.

The end product of this process should result in a body of information that can be translated into learning that an agency can leverage towards preventing future identical or similar scenarios. We learn best from our mistakes so as to not repeat the same mistake. Let each event evolve into a research project for your organization to consistently and thoroughly investigate the what, and why of the event and utilize that information to drive improvement. These events are unfortunately predictable, but that does not excuse us from capturing every opportunity to make them preventable as well.

Jonathan Olson is the chief of operations for Wake County Emergency Medical Services and assistant fire chief with the Wendell Fire Department. He is a graduate of the NFA Executive Fire Officer program, has over 25 years of experience in EMS and fire operations, and is a co-author of “Management of Ambulance Services” by NEMSMA.
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Issue 33.4 | Spring 2019

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