BOS 4601 Unit VII Assessment

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While responding to an accident where a forklift tipped over going around a corner, the supervisor tells you that the cause was simply operator error since the driver was going too fast. The supervisor does not see the need to investigate any further. If you were the manager of this site, what would you say to the supervisor?  

  While the question above does not say that an injury or damage to the forklift occurred, because it classifies this incident as an accident, I will assume that this was an unintended event that caused injury or damage (Oakley, 2012). As a supervisor, it is expected that he/she understand that accidents such as this are never that simple.  In fact, I would be distressed that one of my supervisors had this mind-set and would have an in-depth conversation with that person.  Simply put, this supervisor does not yet understand that an investigation needs to be completed to find out exactly what caused the forklift to tip over.  As an agent of the organization, this supervisor should be invested in not only the welfare of his/her subordinate, but the loss of money that the company will incur because of this accident. Furthermore, finding corrective actions so that an accident like this never happens again is paramount (Oakley, 2012).Knowing that not every accident is the result of human error or negligence, as the supervisor seems to think, a trained investigator would utilize certain techniques to explore other ideas such as the forklift’s operating systems, potential alarm systems, speed brake malfunctions, training (or lack thereof) issues, intoxication or prescription/over-the-counter drug use, inattention, the forklift load being overweight, and so on.  By involving the supervisor in this process, he/she might better understand and learn from this experience as well.

       Trained investigators might utilize the fault tree process for this particular incident.  In this case, the investigator would start with the top event being the forklift tipping over and causing injury and/or damage.  The next step would be to determine the events necessary to produce the top event and corresponding logic gates; speed of forklift, training of operator, load on forklift, alarm or speed limiting systems working or not, divided attention factors, sleep / intoxication, forklift maintenance, and so on.  The idea would then be to continue the tree until the investigator reached a point at which there are no more events (Oakley, 2012).  Developing a fault tree for this incident, and including the supervisor in this process, would not be difficult and would be a practical way to graphically portray this accident.  The interview process following an incident like this would be important as well.  Careful and deliberate discussions with the driver, witnesses, supervisors, maintenance staff, and co-workers would aid in better understanding what happened and how this event took place (Oakley, 2012). 

       From the fruits of this investigation, management would be presented with casual factors that led to this happening, reasons why it should not have occurred and, perhaps even more importantly, a comprehensive corrective plan so that this accident in never repeated (Oakley, 2012).  By actively involving the supervisor in this process, he/she has the opportunity to grow and learn as a trusted member of the organization; to better protect the company’s financial and staffing interests. The supervisor would then be better equipped to proactively supervise subordinates in the future so injury does not befall any of them on his/her watch again.     


Oakley, J. S. (2012). Accident investigation techniques: Basic theories, analytical methods, and applications (2nd ed.). Des Plaines, IL: American Society of Safety Professionals.

Oakley, J. S. (2012). Accident investigation techniques: Basic theories, analytical methods, and applications (2nd ed.). Des Plaines, IL: American Society of Safety Professionals.

You recently completed an accident investigation involving a worker injured by an unguarded blade on a table saw. The investigation revealed that the guard had been removed some months before by persons unknown. Propose one corrective action for each of the first six levels in the hazard control precedence that would help prevent the accident from happening again. Which one(s) would you recommend, and why? 

 Although organizations use different terms to describe fixing a problem that resulted in an accident, Jeffrey Oakley points out in his 2012 book, Accident Investigation Techniques, that “recommendations” and “corrective actions” seem to be the most widely used. The hazard control precedence displays the order in which hazard control methods should be considered when determining what corrective actions apply to certain situations (Oakley, 2012).  The strategy has seven priorities or levels that are used to create these corrective actions to lessen or eliminate a hazard; design to eliminate hazard conditions, design for minimum risk, design in safety devices, design separate warning devices, develop operating procedures and train staff to use them, developing administrative rules, and requiring management to accept risk (Oakley, 2012).

       In this scenario, the design to eliminate hazardous conditions was initially in place, but was removed by unknown person(s) at some point.  The remedy for this condition would be to reinstall the protective guard with one-way or locking hardware.  This would eliminate or reduce the chance of the guard being removed again in the future.  If the investigation were to reveal who removed this device in the first place, administrative action(s) and discipline up to and including termination should be recommended.  This would send a message to other employees that removing protective guards or equipment will not be tolerated.

       The next level is to prioritize the design for minimum risk (Oakley, 2012).  By incorporating an alarm or stop-function that would disable the device should the guard or any other piece of protective equipment be removed or disabled would minimize risk.  Equally important would be training operators in this alarm and how to ensure it is working properly.

       Level three is the actual design of the safety device(s).  By deploying a safety guard with alarm or stop-function, the design would need to be able to function when operating safely and stopped when not in place.  By adding locking or one-way fasteners, this safety device could no longer be easily removed and improved by design.

       Priority four is the design of separate warning devices and was partially touched on above.  In addition to the warning alarm, adding additional signage and controls like a hood over the power button would decrease risk of injury by forcing the operator to slow down.  The addition of signage displayed on top of or directly adjacent to the covered power button would ensure attention to detail and slower operation occurs before use.  Training in these items would be required as well.

       Oakley explains that the development of operating procedures and the training of personnel on these procedures and rules is in step five (Oakley, 2012). Developing initial and annual re-certification training requirements for operators of this device would ensure each employee is versed in the safe operation and proper use of all if its safety equipment.  By requiring reoccurring in-service training, updates and additions could be implemented as needed as well.

       Finally, developing administrative rules such as requiring a management team member to inspect the device no less than weekly should be implemented.  Proper documentation of this weekly inspection and the in-service training events would increase safety and lessen the likelihood of safety equipment being removed in the future.  This documentation also provides written evidence that the organization takes safety seriously and can be used later in court to discredit evidence presented to the contrary.  Written policy and procedure is meaningless without follow through and regimented adherence.  Policy makers must have input and buy-in from stakeholders during the development of these rules.  Having this insures complete understanding that safety is serious and is everyone’s job.    


Oakley, J. S. (2012). Accident investigation techniques: Basic theories, analytical methods, and applications (2nd ed.). Des Plaines, IL: American Society of Safety Professionals.


Oakley, J. S. (2012). Accident investigation techniques: Basic theories, analytical methods, and applications (2nd ed.). Des Plaines, IL: American Society of Safety Professionals.

Recall your submissions for the projects in Units IV, V, and VI. Using the causal factors for the 2007 propane explosion at the Little General Store in Ghent, WV. that you have previously identified, determine the level of accountability for each causal factor (worker/equipment, supervisor, management, corporate). Propose at least one corrective action for each causal factor.

For units IV, V, and VI, students like myself were introduced to various investigative techniques used to identify causal factors following the 2007 propane explosion at the Little General Store in Ghent, West Virginia. By using an events and causal factors chart, a barrier analysis worksheet, and a fishbone diagram, we have been able to graphically see the relationships between causal factors, ineffective or unused barriers, and the accident itself. These charts illustrate what factors led to the explosion and help isolate areas wherein corrective actions could prevent, or at least minimalize injury and damage in the future.

In this case, one of the main causal factors revolved around training and the lack thereof. A safe workplace, even without extremely dangerous materials like flammable propane, must be maintained by trained employees, supervisors, and managers. Recognizing hazards and ensuring that those at risk are properly trained is paramount to managing that risk. According to Oakley, there are four levels of accountability that can be utilized in finding casual factors. These levels are worker/equipment, supervisor, and management/corporate (Oakley, 2012).

The casual factors that I found following my research, charting, barrier worksheet, and fishbone diagram are; the propane tank being located too close to the building and being there uninspected for +10 years, the junior technician lacking the needed training to perform his position while being left unattended, an undetected defect in the propane tank’s valve that was not found due to missed maintenance opportunities, local fire and first responders not being trained in regard to the dangers posed there and how to respond, and there was no written procedures/policy for emergency propane response.

The junior technician was left unattended after not receiving a safety briefing or the correct amount of training for this action. When he was presented with the defective valve, he did not know how to respond nor did he evacuate the area. In fact, the junior technician did not initially call 911, he called the senior technician. By not evacuating the area and not calling 911 immediately, uncontrolled liquid propane was able to fill the store, which was too close to the tank. When 911 was ultimately contacted, the volunteer fire response did not maintain the proper training to recognize the threat presented. While the fire department called for the store’s closure, the people were still allowed to maintain in the area. Within minutes, the explosion occurred resulting in death and injury.

While it is easier for some to assign accountability upward, the worker himself bears some responsibility for not questioning the senior technician choice to leave him alone. The next level accountability falls on worker/equipment in the senior technician for not providing a safety briefing, not training the junior technician, and then still choosing to leave him unattended.

The casual factors point the next failure was on the part of Ferrellgas who did not make sure the tank was in the correct location per code and in good working order regarding the valve. Management’s failure to follow code and law in regard to placement, training of staff, and training of local first responders is noted. This failure resulted in the lack of evacuation and was completely preventable. The active safety features on the tank itself were not in good working order due to not being properly inspected; another management issue that was not taken into account.

Corrective actions include third-party training to be provided of all staff members upon hire and annual recertification required. When tank is installed, for a use permit to be valid, training of all local responders must be signed off and completed. These permit expire annually and shall be renewed each year. Company policy and procedures to indicate that junior technician shall not perform any propane related function if senior technician is off site. Written policy and procedures manual should be posted in clear view of all staff members at all times. Signage to include emergency response numbers should be posted in clear view. This signage should include instructions to evacuate the area immediately and call 911 in case of emergency.

As I learned following these units, this accident was completely avoidable. The injuries, destruction, and loss of life should not have happened and should not happen again. Barriers were in place but not used. Simple actions and faulty equipment led to poor decision and ineffective responses. Through hindsight and forward thinking, incidents similar to this should not be repeated.


Oakley, J. S. (2012). Accident investigation techniques: Basic theories, analytical methods, and applications (2nd ed.). Des Plaines, IL: American Society of Safety Professionals.

Three workers were assigned to replace a water valve located in an underground concrete vault. After removing the manhole cover, worker #1 climbed down the ladder into the vault. Worker #1 collapsed and became unconscious within seconds of reaching the bottom. Worker #2 went down the ladder to rescue worker #1 but was quickly overcome by the lack of oxygen. Both workers died at the bottom of the vault. Worker #3 stayed outside the vault and called for emergency response after worker #2 collapsed. 

Develop a list of five questions you would ask a witness to the accident.

When investigating an accident of this magnitude wherein someone tragically died, it is important to ensure witnesses feel safe and reassured. By explaining the reason for the interview and conducting it in an area that allows for the most comfort as possible, the investigator will likely be more successful in gleaning important information. Taking time to build rapport with the witness is important to ease any feelings as though he/she is on trial or being interrogated (Oakley, 2012).

I would open the interview by explaining who I was and why I was there. Expressing that the witness is important, but not in trouble, will help answer questions as to how this incident occurred and how to prevent such an accident from happening again. Starting with basic and secondary contact information, I would simply ask them to tell me what happened in their own words. By asking this quick and open ended question, it allows the witness to tell their uninterrupted story, free of questions, and can put them at ease (Oakley, 2012).

By saying things like, “I just want to make sure I heard you correctly” or “So I understand what you said was”, and then repeating what they told me, I would be able to verify their statement for my notes as well as it allows them the opportunity to expand with more information at that later time. A good investigator never asks leading questions and allows a witness, however inaccurate it may be, to say what it is they want to say (Oakley, 2012). That is not to say an investigator should not question or challenge a statement, but asking leading questions allow for responses from witnesses molded around what they think the investigator is looking for and may not be accurate.

Establishing where the witness was physically located when the accident occurred is important and should be documented not only via the question and answer, but on diagrams and sketches as well. Determining where someone was in relation to the accident may lead an investigator to ask certain questions based on proximity. A solid investigator should also ask what equipment the witness was wearing and using at the time of the accident to clarify if they could have even seen or heard what it is they are claiming. Those with blocked views of an incident may not have seen something as clearly as others, but that does not mean they could not have heard or felt something either.

By asking about relationships in terms of friends, co-workers, enemies, lovers, all of these types of relationships must be ascertained. Those who care a great deal about the injured person may, either intentionally or not, alter their story to protect them. Opposite could be true if that person did not like or get along with the other party. In general, I would ask open ended questions so as to get an overall picture of the events as perceived by the witness. In closing it is important to ask them what they thought caused the accident and how it could have been prevented. Going forward, asking a witness how we could prevent this type of accident from occurring again in the future, allows for the witness to feel part of saving others from the same type of event and ends the interview on high note; working together so this does not happen again to someone else.


Oakley, J. S. (2012). Accident investigation techniques: Basic theories, analytical methods, and applications (2nd ed.). Des Plaines, IL: American Society of Safety Professionals.

Two workers were assigned to replace a water valve located in an underground concrete vault. After removing the manhole cover, worker #1 climbed down the ladder into the vault. Worker #1 collapsed and became unconscious within seconds of reaching the bottom. Worker #2 went down the ladder to rescue worker #1 but was quickly overcome by the lack of oxygen. Both workers died at the bottom of the vault. Worker #3 stayed outside the vault and called for emergency response after worker #2 collapsed. 

Applying the “four P” evidence concept (physical, paper, people, and photographic), discuss the evidence related to the accident that you would want to collect. 

Because evidence is anything that can be used to gain facts or knowledge about an accident (Oakley, 2012), securing as much as possible at an accident scene is vital to a proper investigation. In general, there are four types of evidence in accident investigation. Referred as the Four P’s, they are; physical, paper, people, and photographic (Oakley, 2012). While there can be endless streams of evidence in some cases, others can be more challenging to locate even the simplest, but the investigator must attempt to find it. Many investigators agree that wasting time on endless streams of evidence that has no bearing on the case can be as important as finding the smallest crucial piece that determines exactly how or why an accident occurred (Oakley, 2012).

In this scenario, getting prompt photographic evidence of the undisturbed scene could prove to be critical. Because this case resulted in a double fatality, there will likely be litigation and much thought put into the investigation by others after the fact. Hiring a trained investigative photographer would be a good idea if it was within the budget parameters of this investigation. If not, I would consider videotaping the scene as well. Doing this could be important when looking at component failures, disconnects, safety violations, ladder construction/location, and so on. While a few good photos or videos are better than many bad ones, the goal is to take enough of either so as to allow someone who was not on-scene to feel as if they were (Oakley, 2012).

Gathering physical evidence must be done with care and protection in mind. Placement of these items must be documented and visual evidence like signage in this case would be imperative. Seeing the warning enclosed space signs there or no, but be documents and ideally photographed as well. In terms of paper evidence, some might be gathered days or even weeks later like training certifications for doing the work these employees were tasked with. Job orders, manager instructions, field notes, all these items would need to be secured as quickly as possible. Because of liability fears, this may require subpoenas and the investigator shoud be prepared for this.

In gathering people evidence and interviewing witnesses, care must be taken to utilize previously discussed tips and techniques. Audio or videotaping these interviews would be something I would strongly consider and could easily justify in a double fatal accident investigation. Getting the most accurate statements as close to the time of event is desired, but even if it takes time to get it, a late interview is better than not interviewing someone. Especially in a case such as this wherein someone could show up years later at trial with one-sided information that would be difficult to counter after the fact.

The time to stop gathering evidence varies upon the complexity of the accident in question (Oakley, 2012). In this case, it should continue until the investigator can establish sequence, causal factors, and is able to develop corrective measures; all of which could take considerable amounts of time. While for small accidents or near-misses, one might stop collecting evidence once casual factors and sequence were determined, in this case it would be imperative to develop actionable corrective measures so no one else has to experience the pain and misfortune of having an employee, loved one, relative, or co-worker die.


Oakley, J. S. (2012). Accident investigation techniques: Basic theories, analytical methods, and applications (2nd ed.). Des Plaines, IL: American Society of Safety Professionals.

Explain the four levels of accidents, providing an example of each. How are the categories different from each other?

Jeffrey Oakley, in his 2012 book, Accident Investigation Techniques, relates there are four levels of accidents and he categorizes them as; Near Miss, Minor Injury, Major Injury, and Catastrophic Injury. While taken at first glance, some might say that list is fairly self-explanatory, but in today’s day and age of litigation and deep pockets, most would agree that nothing but good things can come from complete, accurate, and proactive investigations.

Although related, these categories are independent and separate from each other. A near miss is an incident that could have potentially caused any type of accident involving damage to property, first-aid injury, or even something catastrophic such as a fatality. Near misses are different from the others in that they do not involve injury or damage, although they very well could have (Oakley, 2012).

A minor injury or first-aid case is one wherein a person has been injured, but can be treated on-scene and without a professional medical response. First-aid cases are different from the higher level injury cases because there is no need for a licensed medical professional to attend or treat the individual (Oakley, 2012). In a minor injury/first-aid case, an example would include an employee opening a letter with a letter-opener and poking him/herself with it. The injury caused discomfort and a bandage, but did not require stiches or treatment from EMS.

In major injury cases, a recordable injury resulted after an accident and that injury requires the attention of a licensed medical professional (Oakley, 2012). An example might include a set of tools falling on an employee that resulted in a laceration that requires stiches to close. The employee may also need a prescription for follow-up medication.

As opposed to major injury cases, a catastrophic injury involves those accidents wherein a person or persons were killed, major property damage resulted, and/or multiple people were injured at the same time (Oakley, 2012). An example might be a railway worker was cleaning the tracks and a train, which was supposed to stop for a red signal, continued on and struck the worker. If the worker was killed or sustained great bodily injury, this recordable case would be catastrophic.

Oakley, J. S. (2012). Accident investigation techniques: Basic theories, analytical methods, and applications (2nd ed.). Des Plaines, IL: American Society of Safety Professionals.

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