NAME WITHHELD BY REQUEST
Recently, I had the opportunity to investigate a rollover mishap on an Army installation involving an explosives-laden vehicle. What I discovered opened my eyes as to how often production overrides safety.
I was alerted to the mishap by the sound of sirens. I immediately turned on my radio and monitored the subsequent communications. After informing my supervisor of the situation as I knew it, I grabbed my camera and clipboard and drove to the scene. Security guards had closed off all avenues of approach from nonessential personnel while first responders and quality assurance specialists (ammunition surveillance) deemed the scene safe. Eventually, I was allowed into the scene to conduct my initial investigation.
Being a law enforcement officer when not working for the Army, I approached my task as I would for any vehicle accident. I photographed the entire scene, beginning with the exterior and working my way toward the center. I have found through experience that people in stressful situations tend to attempt to rationalize their actions. Keeping quiet and listing to the driver, munition handlers and supervisors, I was able to ascertain the factors which led to the mishap. The following is a synopsis of what I was to build based upon the words spoken by those involved and photographic evidence.
On the day of the accident, a newly hired truck driver was tasked with picking up a load of 2,000-pound general purpose bombs (16 in all) from a magazine group and transporting them about 3 miles to another location. There, they would be offloaded and sawed in half for demilitarization. While the driver positioned his trailer just outside the doors of the earth-covered magazine, a crew of munitions handlers were inside with a Skytrack forklift. Their job was to retrieve the correct bombs — verifying their national stock numbers, lot numbers and condition code — and place them on the trailer.
Normally, munitions would be loaded onto a trailer as to distribute the weight evenly, following a load plan in accordance with operational procedures. In this instance, however, the munition handlers, knowing they only had a Hyster forklift at the demilitarization location, positioned the load on the driver’s side of the trailer. (Unlike the Skytrack, the Hyster does not have the ability to extend its forks.) Unfortunately, the driver, who was new at the job and improperly trained by his employer, did not object to the load placement.
After the load was secured, the driver departed, turning left out of the magazine group and then left onto the road leading to the demilitarization area. When he later executed a right-hand turn, the vehicle’s inner wheels lifted off the road and the misaligned load weight caused the trailer to overturn and come to rest on its left side. The driver was able to exit the cab of the vehicle and call for assistance, which led to the emergency response.
A few days after the incident, I was invited to speak at a monthly safety meeting to an audience of more than 70 directors, managers and supervisors. What I shared with them hopefully opened many eyes to what I believe to be a systemic problem of production overriding safety. I broke down the entire incident using a phase diagram and decision tree. I told them that while the accident may have occurred on the day of the rollover, it actually began during the planning phase of the operation. Decisions made beyond the initial planning allowed this incident to occur. Pressing, complacency and failure to enforce existing rules were all underlying factors.
Basic leadership involvement could have prevented this incident, subsequently breaking the chain of events which led to the rollover. During the initial planning, the equipment needed to complete the task should have been identified and leadership should have ensured it was on hand. For example, a second Skytrack forklift was located within a half-mile of the demilitarization location, where the less-capable Hyster forklift was to be used to offload the munitions.
An employer has the responsibility to ensure all employees work within a safe environment and can identify hazards associated with the tasks they are preforming. That didn’t happen in this case. The improper placement of the 2,000-pound bombs caused a dangerous condition, and the driver’s inexperience led him to accept a hazardous load. It is our (leaders and safety professionals) responsibility to educate all personnel on how to implement risk management into their everyday lives.
Fortunately, this accident didn’t lead to any injuries, but it did open many eyes. Completing the mission is important, but we can never let production override safety.