A Primer for Incident Investigation

1. A Primer for Incident Investigation Joe Batarse, Aquatic Director Trish Delgado, Aquatic Director City of Los Angeles Department of Recreation and Parks

2. Introduction • Injury and Illness Prevention Program: California Code of Regulations, under Title 8, Section 3203 of Cal-OSHA. • Elements: Authority and Responsibility, Methods of Compliance, Communication, Hazard Assessment, Correction of Unsafe Conditions, Training and Incident Investigation

3. Introduction Presentation Outcomes: • Introduce a diagnostic tool that methodologically guides an incident investigator • A practical application of the diagnostics tool • An overview of contemporary risk analysis • Handouts to assist with incident investigations

4. Incident Diagnostics Incident diagnostics has two ends in mind • To determine the pathology of the incident • The avoidance of a future occurrence through a process of review and adaptation

5. Spider Traps • SEQUENCE OF EVENTS • PERFORMANCE • IDENTIFY AND • DETERMINE CAUSATION • EVALUATION • RECOMMENDATIONS • TRAINING • RESOURCES • AMBIANCE • POLICIES, PROCEDURES, PRACTICES, PHILOSOPHY, PRODUCTION PRESSURES

6. Diagnostic Methodology SPIDER: Sequence of events the mechanics of the incident Performance review before, during and after an incident Identify relevant factors and Determine their causation Evaluation: TRAPs (Conditional analysis: If this, then that.) Recommendations: TRAPs revisions need to be mindful to the intended goal and to any unintended consequences

7. Diagnostic Methodology TRAPs reviews categorical factors “T” for Training Pre-employment Age, certification requirements, physical condition, and water skills competency After-employment Number of staff and workload*, experience, expertise, and relevant additional training, *Workload can be assessed here or under Ambiance (Tangibles).

8. Diagnostic Methodology “R” for Resources Assets, equipment, materials, and supplies Sufficiency in number and type for the tasks required Updated (is there a stale date) and functional Accessibility/mobility of assets

9. Diagnostic Methodology “A” for Ambiance-environmental factors Tangibles – Water quality, air and water temperature; type of facility; time of day and year; workload* (bather load, activities, programs); staffing level; facility features and size, design and configuration. Intangibles – Staff synergy, attitude (general and task specific); organizational culture and climate, and unachieved goals/objectives. *May be assessed here or under Training: After employment concerns.

10. Diagnostic Methodology “Ps” for Policies, Procedures and Practices, and organizational Philosophy and Production pressures

11. Practical Application • Application of the SPIDER TRAPs diagnostic tool Two recent incidents: A male in his 50’s performing lung busting exercises. A 15 year old female synchronized swimmer practicing breath-holding.

12. Practical Application Spider Traps • Sequence/mechanism of the incident: Both incidents involved hypoxic training • Performance: Staff members were at appropriate duty stations Staff initiated and followed the EAP according to training specifications Facility was secured, privacy preserved and questions were directed to the PR Office. Paperwork, staff and witness statements were filed and the chain of command notified.

13. Practical Application Spider Traps • Identify relevant facts and • Determine causation Both cases shared similarities. Staff was aware victims were engaged in “lung busting” activities but failed to act In case 1, staff failed to intercede since the victim was an adult In case 2, the victim was an athlete who regularly attended team workouts In both cases staff failed to recognize the activity as risky behavior.

14. Practical Application Spider Traps TRAPs portion of the analysis • Training Determined it was deficient Staff was not trained to recognize hypoxic training as risky activity; consequently the public was not being educated since the pool rules did not prohibit the activity Follow up Staff underwent retraining and pool rules were altered to prohibit the activity. Coaches were trained in the dangers of hypoxic training

15. Practical Application Spider Traps • Resources Not a concern since staff training could be incorporated into the existing training program with little expense

16. Practical Application Spider Traps • Ambiance Tangible level Warning signs prohibiting hypoxic training were placed throughout the facilities Staff was tasked with enforcement and educating the public regarding the activity and consequences of the activity Intangible level The new training created a culture that viewed the activity as dangerous

17. Practical Application Spider Traps • Policies – Procedures were written and made available to staff Procedures were incorporated into the operational manual Ensured changes were consistent with our organization’s philosophy and practice of preventative lifeguarding

18. SPIDER TRAPs Recommendations: • Developed a workplace culture that equated hypoxic training as risky behavior akin to diving in shallow water, and initiated new training standards • Posted signs, changed the Pool Rules to educate the public as a means to promote prevention • Policies were memorialized and we formalized procedures to change workplace practices

19. Contemporary Risk Analysis The Structural Divide: Accidents and Incidents distinguished • Incidents involve failure of parts or units within the system • Accidents result in subsystem or system damage • Goals or objectives intended

20. Contemporary Risk Analysis Incident Precipitating Triggers • Malfunctions • Errors • Violations

21. Malfunctions (Failures) • Materials – Inappropriate or substandard for the intended use. • Manufacturing – Processing deficiency or flawed engineering. • Operator – May be related to materials, manufacturing, or an inappropriate work environment. Lets look at an example:

22. Malfunctions (Failures)

23. Errors Errors: Require Intent Intent has two elements • Method – An indication of the means by which to be achieved. • Goal – an expression of the end-state to be attained.

24. Errors Errors are classified as “Mishaps” or “Mistakes.” Example: A rancher decides to “put down” his old horse. • A mishap is an execution failure – The rancher takes aim but hits the neighbor’s horse. • A mistake is a planning failure – The rancher takes aim and hits the intended target, but the target turns out to be the neighbor’s horse.

25. Errors Execution and planning failures are collectively referred to as “error types.” Error types involve either: • Failure of expertise where some pre-established plan is applied inappropriately. • Lack of expertise where the individual is forced to work out a plan of action in makeshift fashion because no appropriate plan of action exists.

26. You Make the Call Remember: A mishap is an execution failure involving an unintended target: I throw a rock at Paul but hit Peter. A mistake is a planning failure where the intended target is misidentified: I throw a rock at Peter thinking he’s Paul.

27. You Make the Call Mishap or Mistake? Cowboy shoots his foot drawing his gun.

28. You Make the Call Mr. Pillsbury spills coffee on himself while stepping out the car door.

29. You Make the Call Newspaper headline: “Cops take aim at assailant but wound hostage”

30. You Make the Call Newspaper headline: “Cops take aim at assailant who turns out to be the hostage”

31. You Make the Call Dr. Carnap extracts the healthy bicuspid when he examines the patient’s x-ray backwards.

32. You Make the Call Lori gives Willy a warm-felt congratulatory pat and sends his toupee flying into his birthday cake.

33. Violations Violations are best described in a social context, where behavior is governed by operating procedures and codes of practice. Violations are generally not malicious and, in fact, may be well intended. Two types of Violations: Routine Exceptional

34. Violations Routine violations are deliberate but not reprehensible deviations from those practices prescribed by administration. Two factors contribute to routine violations: • The natural human tendency to take the path of least effort. • A relatively indifferent environment (i.e., one that rarely punishes violations or rewards observance). “Consequences shape and maintain behavior.” – B.F. Skinner

35. Violations Behavior ascribes meaning to a message. Lacking enforcement, messages are distorted to suit the bias of the receiver. Example: Question: When does a yellow light signify speed up, not slow down?

36. Violations Answer: When everyone seeing the yellow light accelerates. This is the social dimension to violations. Violations become acceptable when everyone indulges. Remember routine violations prevail because people seek the path of least effort and an indifferent work environment permits it.

37. Violations When rule-breaking behavior makes life easier without paying the consequences for the violation, the likelihood for a future violation becomes inevitable because the rationale for the rule is ignored in pursuit of the path of least effort. Management’s credo: The challenge is to make the predilection for rule-violation behavior uncomfortable enough to insinuate rule observance.

38. Violations Exceptional Violations: Arise out of a cluster of significant conditions; the product of “system double-bind.” As systems grow complex, double binds become more prevalent. Double-binds are a product of: • Competing interests – unstated or misaligned goals. • Production pressures – “bottom line” objectives. Routine and exceptional violations can lead to equally catastrophic consequences.

39. You Make the Call Game: Is it a Routine orExceptional violation? Review: Routine violations are deliberate but not reprehensible deviations from those practices prescribed by administration. Exceptional violations arise out of a cluster of significant conditions (competing principles) that make violations inevitable.

40. You Make the Call Routine or Exceptional Violation? Tina takes a shortcut through the flower beds to reach the library.

41. You Make the Call Captain Pickwick overloads his ferry to compensate for rising fuel costs.

42. You Make the Call Chef Ardee skimps on the truffles and uses margarine instead of butter in his recipe.

43. You Make the Call Kelsey fails to inform the financial aid office of her job promotion fearing the loss of her education grant.

44. You Make the Call Lifeguards take off shirts and don’t apply sunscreen while on duty.

45. You Make the Call Coroner Einhorn keeps his sack lunch in the specimen fridge.

46. Practical Exercise • Identify and determine the relevant issues and the corrective changes needed using TRAPs to prevent the incident in the future.

47. Practical Exercise • A drowning occurs at one of your swimming pools • The victim is a 12-year old male from a local day camp • Through your investigation you learn staff responded to the emergency appropriately • You learn from a camp counselor the victim suffered a seizure while on the bus in route to the pool. Your source also confirms that the victim has a history of seizures.

48. Practical Exercise Conclusion: TRAPs Analysis Relevant factors: • Communication (T, A, Ps) • Establish specific procedures with day camp counselors (T, Ps) • Consider additional counselor training to identify conditions that potentially preclude water activities (T, P) • Know/establish the camper/lifeguard ratio (T, R, Ps)

49. In Review: The Structural Divide and Incident Triggers Dynamics Overview Malfunctions Failures INCIDENT Units and Parts Errors Damage ACCIDENT Subsystems Systems Violations

50. Additional Info Investigation: Questions should be specific to the incident but also include core (directional) questions: Include pre-assembled checklists: Resource Information Packets (RIP) Investigative team: Two investigators; one de-briefer Cal-OSHA Incident Investigation: http://www.dir.ca.gov/DOSHPol/P&PC-170.HTM Contact info: 323-906-7953 Joe.batarse@lacity.org Trish.delgado@lacity.org