Accident Case Study: Kosovo

1. Accident Case Study: Kosovo

2. Background to the accident 1 This accident happened in an area with detailed minefield records showing that 210 PMR-2A and 380 PMA-3 mines had been laid there, but the record did not include an accurate map showing where the mines were. Unusually, this accident happened while access was being gained in order to carry out an investigation of a previous accident.

3. Background to the accident 2 A path was being cleared through the area to reach the place where a deminer had stepped on a mine during survey. To maintain safety distances, the work was being conducted by one deminer at a time, each working for one hour. Work had been delayed by rain for an hour immediately before the accident.

4. Background to the accident 3 There were small trees in the area, some undergrowth and the ground was covered with leaf-litter. It was less than two years since the mines had been placed so they were expected to be in a functional condition. The PMR-2A tripwire operated mines meant that this was classed as a ‘high risk’ area.

5. Background to the accident 4 At 17:00 the task supervisor assessed progress and realised that they would not reach the site of the previous accident that day, so he decided to conduct what he called a ‘reconnaissance’” to speed things up. The accident happened where the yellow-topped stake is shown. The stake was placed after further search and clearance had been conducted for the second investigation.

6. The accident 1 The Task Supervisor checked his metal-detector by passing the search-head over his boot. Without cutting any undergrowth, he then swept the search-head over a small area of ground beyond the base stick and, having got no signal, stepped onto it. He then used the metal-detector over another small area and moved a foot onto that, so progressing into the hazardous area.

7. The accident 2 Because he was not removing undergrowth, he selected areas without much undergrowth to search with the metal-detector and then step onto. Without removing vegetation like this, it would have been impossible to move the detector search-head in a sweeping ‘side-to-side’ search-pattern.

8. The accident 3 After advancing five metres in one direction, he decided that he was heading in the wrong direction and turned. His route traced a semi-circle. After he had passed to the other side of the marked search lane, he stepped on a PMA-3 blast mine. The time of the detonation was recorded as 17:05, so he had advanced very quickly.

9. The accident 4 The supervisor sat down, then realised he was not badly injured so got to his feet and staggered back towards the cleared lane where a deminer was already prodding towards him. The supervisor stated that he had searched the area where the mine detonated and got no metal-detector signal. The picture shows the supervisor’s boot near the accident site.

10. The accident 5 This photograph was taken as the supervisor was being evacuated by four team members. The deminers carried the supervisor back to the place where the access lane had been widened to two metres. Can you identify any errors?

11. The accident 6 The one metre wide lane was overcrowded and this might have caused further injuries if people stepped outside the tape. Visors were not worn or worn raised. Where was the deminer taking pictures standing?

12. The accident 7 Two medics arrived as they reached the wider lane, so the deminers withdrew. The medics gave first aid, then used a stretcher to carry the victim to the ambulance. The casualty arrived at the hospital within an hour of the accident and the MEDEVAC and the treatment given were accurately recorded.

13. The victim’s injuries The recorded injuries were: • A severe foot injury with three of his toes dislocated/disrupted with minor bleeding. • Small face wounds. • A small wound in one eye.

14. Investigation The Mine Action Centre sent a team to investigate the accident. They oversaw the search and clearance of the area to the accident site and wrote a detailed report. The demining organisation involved was entirely open and transparent and made all information available to the investigators.

15. Investigation The victim's metal-detector was checked and found to be working properly. The investigators found that the site was marked according to SOPs and had appropriate communications. The picture shows a PMA-3 and associated indicators found in the area.

16. Researching the injuries The victim’s injuries were not as extensive as they might have been if another mine had been involved. In the accident records in the Database of Demining Accidents (DDAS), the results of stepping on a PMA-3 are very varied. In more than half of them, the victim did not suffer enough injury to require a foot to be amputated.

17. Researching the injuries 2 The PMA-3 has a small 35g Tetryl explosive charge which is in the centre of the mine. If the victim steps directly on top of this, part of the foot may be traumatically amputated and dame will be such that the remains will usually need to be surgically amputated. However, when a victim steps on one side of the mine, the charge is not directly under their foot and they can escape with far less injury. Two deminers have detonated a PMA-3 by standing on it and walked away with no more than bruises.

18. Researching the injuries 3 The Victim’s body armour apron was undamaged. He was wearing a helmet and visor which was damaged in a way that could only have occurred if the visor was raised at the time of the detonation. The deminers sought to protect their Supervisor by saying the visor was down, but he admitted it was raised. Loyalty to the team has led to witnesses lying because they think they are protecting their colleagues in many accidents.

19. The metal-detector The victim claimed that the metal-detector did not signal in the area. The shallow crater is shown in the picture. The PMA-3 is a minimum-metal mine but it was very near the surface so the metal-detector should have signalled over it. However, the victim did not check the metal-detector using an actual example of the mine, so the metal-detector may not have been ‘tuned’ to find the mine.

20. The metal-detector search method The metal-detector had a double-D search head. These metal-detectors signal when there is a different signal under one side of the search head from the other, which can make pinpointing easier. If the search head is lowered to the ground with the mine beneath the central bar, the metal-detector will not signal until the search head is moved from side to side.

21. The metal-detector’s limitations The deminers reported that the metal-detector was unreliable when it was wet, and it had been raining earlier that day. The victim moved approximately 10 metres in a little over five minutes using the metal-detector whereas the previous search and clearance rate had been about 5 metres an hour. While the metal-detector may have failed, it was likely that it was used without sweeping from side-to-side, without overlapping or simply too quickly.

22. Investigation 2 The investigators checked the victim's metal-detector and decided that it was working properly. They found that the site was marked correctly in accordance with the demining organisation’s approved SOPs, had appropriate communications and that the MEDEVAC to hospital was conducted and recorded properly. The picture shows a PMA-3 found in the area.

23. Investigation 3 The damage to the boot and limited injuries suggest that the victim stepped on the side of a PMA-3 with the toe of his boot, and so escaped severely disabling injury by chance. The blast from the mine carried small fragments of mine casing or earth under his open visor, inflicting light wounds to his face and eye, and slightly damaging his helmet.

24. Probable causes Having determined what happened, accident investigators should look for probable causes. An accident investigation should be conducted to find out the truth, not to attribute blame. In this case, the victim blamed the Mine Action Centre for having applied pressure for his team to access the previous accident site quickly.

25. Probable causes In response, the Mine Action Centre’s investigators blamed the victim and recommended that disciplinary action should be taken against him. In most recorded accidents, the victim is blamed but this is not helpful because it does not identify the causes for the accident. If the victim made mistakes, the reasons for that must be found in order to reduce the risk of the accident being repeated.

26. Probable causes 2 The primary cause of the accident was undoubtedly the victim’s decision to conduct an informal reconnaissance inside the hazardous area. He ignored many of the demining groups SOPs while doing so. The victim excused his decision by saying that he was under pressure to find the place of the earlier accident as quickly as possible.

27. Inadequate training? The victim seems to have believed that his method of conducting ‘reconnaissance’ was safe in an area known to contain both tripwire initiated and pressure mines. His visor was raised so he did not wear his PPE correctly and appears not to have understood how his metal-detector worked or how important area-marking and disciplined detector search procedures are to ensuring thorough search.

28. Secondary causes The victim had been given a supervisory role because of his record as a military EOD officer and military demining specialist. This background had prepared him to take command of a group of deminers but it had not prepared him for the way that demining is conducted in Humanitarian Mine Action. Failing to ensure that a senior supervisor had a suitable approach for working in Humanitarian Mine Action was a recruitment and training fault at the organisation’s headquarters.

29. Recommendations The Mine action Centre’s investigators recommended that the organisation’s management should take disciplinary action against the victim. Despite the professional MEDEVAC, they advised that the organisation should carry out MEDEVAC exercises as soon as possible. They also said that the organisation should review their way of testing their metal-detector and include using a test-piece buried in soil.

30. Consequences The Country Manager of the demining organisation gave orders for the recommendations to be carried out immediately. He also reported his concerns over recruitment policy to the Human Resources department at his headquarters. A year later, the Mine Action Centre reported that the victim had recovered fully and was working in a military EOD unit.

31. Summing up This presentation provides an example of a detailed accident investigation that was not conducted as objectively as it might have been. The accident investigators blamed the victim and did not identify the training and preparation failings that were the root cause. The root cause reveal faults at management level that must be addressed in effective Risk Management which prevents accidents being repeated by addressing their causes.