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Incident at…

Start. Incident at…. Continue. Index. Incident Description and Outcome General Information Main findings from investigation Solutions according to the 'simplified' table Additional actions suggested by Hearts and Minds Program Actions taken ('simplified') Summing Up… First-time offence

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Incident at…

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  1. Start Incident at…

  2. Continue Index Incident Description and Outcome General Information Main findings from investigation Solutions according to the 'simplified' table Additional actions suggested by Hearts and Minds Program Actions taken ('simplified') Summing Up… First-time offence Second-time offence

  3. Continue Incident descriptionA pick up driver along with three passengers were on their way to the base for crane reparation work. About 80 km from the destination place the driver (who was allowed only 2,5 hours rest the previous night) fell asleep and the vehicle hit the mountain on the left side of the road. After the impact the vehicle rolled and landed on its roof about 80 meters from the impact point. None of the passangers were wearing their seatbelts Outcome All the vehicle occupants were injured. The rear side passenger sustained major head injuryand after few months in coma passed away. The vehicle suffered extensive damage. Index

  4. General Information Main cause • Driver fell asleep behind the wheel while driving Main findings from investigation • Driver had only 2.5 hours of sleep • Journey Manager failed to challenge/recognize driver’s fatigue • Driver failed to apply the Empowerment to Stop • Driver failed to tell the passengers to wear seatbelt • Driver was trained in Defensive Driving but not on organisation approved course. • Journey Manager was not trained. Summing Up… Index

  5. Summing Up… Index

  6. 'simplified' Suggestions Hearts and Minds Suggestions Main findings from investigation • Driver had only 2.5 hours of sleep • Journey Manager failed to challenge/recognize driver’s fatigue • Driver accepted the assignment knowing he was unfit to drive • Driver failed to tell the passengers to wear seatbelt • Driver was not trained in the approved Defensive Driving course. • Journey Manager was not trained. Summing Up… Index Back to General information

  7. Actions taken Solutions according to the 'simplified' table Back to Main Findings Back to General information Incident description Summing Up… Index

  8. Hearts and Minds Suggestions Immediate Actions ('simplified') Back to Main Findings Back to General information Incident description Summing Up… Index

  9. Next Additional actions suggested by Hearts and Minds Program Back to Main Findings Back to General information Incident description Summing Up… Index

  10. Back Back to Main Findings Back to General information Incident description Summing Up… Index

  11. BACK Definitions

  12. BACK Journey Manager failed to challenge/recognize driver’s fatiguebecause, … • … he believed that the driver was sufficiently rested and therefore did not need to intervene. MISTAKE Back to Main Findings Back to General information Incident description Summing Up… Index

  13. BACK Driver accepted the assignment knowing he was unfit to drivebecause, … • … he was afraid to loose his job. SITUATIONAL VIOLATION Back to Main Findings Back to General information Incident description Summing Up… Index

  14. BACK Driver failed to tell the passengers to wear seatbeltbecause, … • … he was so tired he simply forgot. LAPSE Back to Main Findings Back to General information Incident description Summing Up… Index

  15. BACK Driver had only 2.5 hours of sleepbecause, … • … SITUATIONAL VIOLATION because he did not feel he had any other choice than driving while he was not sufficiently rested. Back to Main Findings Back to General information Incident description Summing Up… Index

  16. BACK Journey Manager was not trainedbecause, … … organisation did not took proper care to train their journey managers to e.g. save some costs. ORGANISATIONAL OPTIMISING VIOLATION, ROUTINE VIOLATION Back to Main Findings Back to General information Incident description Summing Up… Index

  17. BACK Driver was not trained in the approved Defensive Driving Course because, … … organisation did not took proper care to make sure all the drivers took an approved course. ORGANISATIONAL OPTIMISING VIOLATION Back to Main Findings Back to General information Incident description Summing Up… Index

  18. Next Summing up…With the assumption of first-time offence Index

  19. Back Summing up…With the assumption of second-time offence Index

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