Accidents Sequence, and a Haden

¶ … accidents sequence, and a Haden Matrix for the

Accidents Sequence

What Happened

why

Georgia state police investigators determined that the fire truck was traveling too fast for current road conditions.

Driving too fast for conditions

The officer, who was seriously injured in the crash, was not wearing a seat belt and was briefly trapped.

Removing seat belts while the vehicle is in motion

The crash occurred as the fire truck was traveling through an intersection with pavement grade changes occurring at the intersection.

Insufficient training on intersections and difficult road conditions

The victim was pinned between the driver's seat and the roof of the apparatus, upside down with his seat belt fastened.

Insufficient rollover protection for the occupants of the fire apparatus

The victim lost control of the fire truck he was driving, struck a utility pole, and overturned in a ditch.

Driver inexperience with this specific fire apparatus

b. A Haden Matrix

Phase

Human Factors

Vehicles and Equipment Factors

Environmental Factors

Pre-crash

A good driver

Extensive training

Inexperience with vehicle

The morning of the crash, the truck batteries were replaced and the electrical charging system was checked by the county fleet maintenance facility.

Representatives from the Georgia Department of Public Safety Motor Carrier Safety Assistance Program performed an examination of the apparatus post-crash. No violations were reported, and no problems were noted on the report regarding brakes or steering.

Blind curve

Steep lane; intersects in a curve with another two-lane highway. sky clear; weather good

The road surface was asphalt, in good condition, and was dry

Crash

victim didn't use seatbelt excessive speed and loss of control the warning devices on the fire truck were operating, as well as the air horns, water entered cab from broken rear window

Post-Crash

First-aid skills

Access to medics

The power unit for the hydraulic cutting tool that assistants used to cut victim free initially started, but shut down soon after and the fire fighters were unable to restart the power unit

Rescue facilities

Once the table and matrix have been completed, determine the following:

• Identify what you learned from both the table and the matrix.

The Table pointed factor by factor to what happened and to why it happened so a clear cause-and-effect case was drawn.

The matrix helped me evaluate each and every aspect of the situation to see where exactly the fault lay and what could be corrected in the future, as well as matters that were out of the control of remediation (such as environmental factors).

• Identify the similarities between the table and the matrix.

• Identify the differences between the table and the matrix.

Similarities are that both deal with the accident and both try to see what caused it. The Table does it by matching consequence to cause, the Hayden does it by talking all factors of pre-during and post-crash into account.

• Describe the logic behind both risk-reduction measures.