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Vehicle Accident Investigation

Determining Preventability
ollowing a vehicle accident, management should INTERSECTION ACCIDENTS

F conduct a fair, thorough process for gathering the

relevant facts surrounding the incident. An accident
Intersection accidents are common. Many of these
accidents are preventable if the driver:
investigation can assist in litigation defense, provide a •did not control speed to stop within available sight
consistent process for reviewing driver performance and distance;
help identify actions to reduce the possibility of future •did not check cross traffic and wait for it to clear
accidents. An investigation is considered preventable ifbefore entering intersection;
the driver failed to take every reasonable precaution to •pulled out in the face of oncoming traffic;
prevent the accident. A driver could have been obeying •collided with a person, vehicle or object while mak-
the traffic laws and still have a preventable it. This article
ing a right or left turn;
outlines the specifics of determining preventability in the•collided with vehicle making turn in front of
most common vehicle accidents. him/her;
•had collision with vehicle coming from either side,
Accident investiga- DETERMINING PREVENTABILITY regardless of location or traffic signs/signals or whether
An accident is considered nonpre- light was green.
tions can assist in ventable if the driver exercised every
litigation defense, reasonable precaution to avoid the Backing accidents are also common. Many of these
accident. All accidents are preventa-
provide a consis- ble if a driver: accidents are preventable if the driver:
•was not operating at a speed con- •could have avoided backing by planning his/her route
tent process for sistent with the existing conditions of better;
reviewing driver road, weather and traffic; •backed into traffic when backing could have been
•failed to control speed and was avoided;
performance unable to stop; •failed to get out of cab and check path;
•depended solely on mirrors when it was appropriate
and help identify •failed to allow enough clearance; to look back;
•failed to yield right of way;
actions that can •failed to observe existing •when backing a long distance, driver failed to period-
ically recheck conditions;
be taken to reduce conditions; •was in violation of company oper-
•failed to sound horn while backing;
the possibility of ating rules or local, state or federal •while parked at curb, driver failed to check behind
vehicle before leaving;
future accidents. laws and regulations. •backed from blind side when s/he could have made a
sight-side approach;
•failed to use a guide to help him/her back or depend-
Rear-ending another vehicle occurs many times each
ed solely on a guide.
day. Many of these accidents are preventable if the driver:
•failed to maintain safe following distance and vehicle PASSING OR BEING PASSED ACCIDENTS
control; Passing or being passed accidents occur frequently.
•failed to stay alert and note that traffic was slowing Many of these accidents are preventable if the driver:
or stopped; •passed even though view of road ahead was obstruct-
•misjudged rate of overtaking; ed by hill, curve, vegetation, traffic, adverse weather
•came too close before pulling out to pass; conditions, etc.;
•started up too soon or too fast for vehicle ahead; •attempted to pass despite closely approaching traffic;
•failed to leave sufficient room for passing vehicle to •failed to warn driver of vehicle being passed;
get safely back in line; •failed to signal lane change or cut in short when
•was passing and returned to right lane too soon. returning to right lane;
Rear-ending is nonpreventable if: •pulled out in front of other traffic overtaking from
•the other vehicle rolled backward while starting on rear;
grade; •failed to stay in his/her lane;
•the driver’s vehicle was stopped but was hit from •failed to either hold or reduce speed to permit other
behind and pushed forward. vehicle to pass safely.
Accidents while entering traffic occur frequently as
well, and many of these accidents are preventable if the
•failed to check traffic and/or signal when pulling
away from curb;
•failed to look back to check traffic when mirrors
were not sufficient;
•attempted to pull out in a manner that forced other
vehicle(s) to change speed or direction;
•failed to make a full stop before entering from a side
street, alley or driveway;
•failed to make full stop before crossing the sidewalk;
•failed to yield right of way to approaching traffic.
Pedestrian and bicycle accidents are preventable if the
•did not reduce speed in an area of heavy pedestrian
•was not prepared to stop;
•failed to yield right of way to pedestrian;
•failed to stop when passing a streetcar or bus on the
This type of accident is nonpreventable if the pedes-
trian or bicyclist collided with the driver’s vehicle while
it was legally parked or stopped.
•was passing slower traffic near an intersection and An investigation is
needed to make a sudden stop; considered pre-
Sideswipe or head-on collisions are preventable if the •made a sudden stop to park, load or unload, stop at driver failed to
driver: rail crossing, ask directions or because s/he would other- take every reason-
wise pass his/her destination; able precaution
•was not entirely in proper lane of travel; to prevent the
•did not pull to his/her right or left and slow down •made any other type of unnecessary sudden stop; accident.
and/or stop for vehicle encroaching on his/her lane of •improperly parked vehicle;
travel, when such action could have been taken without •rolled backward into vehicle behind.
additional danger; Many of these accidents are nonpreventable if the
•changed lanes without making sure sufficient space
•was legally and properly parked;
was available or properly signaling intent;
•was proceeding in his/her own lane of traffic at a
•was weaving, crowding the passing vehicle. safe, lawful speed
VEHICLE DEFECTS & ACCIDENTS •was stopped in traffic due to existing conditions,
Vehicle defects and accidents occur frequently, and compliance with traffic sign or signal or the directions of
many of these accidents are preventable if the: an official controlling traffic;
•defect was of a type, which the driver should have •was in the proper lane to make turn and their turn
detected during the vehicle pretrip inspection or during signal was engaged;
•was in a disabled vehicle and protected by emer-
normal operation;
gency warning devices.
•defect was caused by the driver’s abusive handling;
•defect was known to driver but s/he operated the MISCELLANEOUS ACCIDENTS
vehicle. Miscellaneous accident types are preventable if the
The struck-while-parked vehicle accident is nonpre- •was making a u-turn;
ventable if the driver was properly parked in a permitted •was pulling away from the curb or other parking
area. space;
•was entering traffic from a driveway or private alley;
STRUCK-IN-REAR ACCIDENTS •was giving a push or was being pushed;
Accidents in which a vehicle is struck in the rear by •vehicle moved due to faulty brakes;
another vehicle occur frequently as well. Many of these •left vehicle unattended (with or without motor run-
accidents are preventable if the driver: ning) and failed to set parking brake and wheel chocks;

Figure 1 Initial Comparative alignment of the competing safety
processes into a cost-efficient manage-
Analysis of TRADOC ment program and office structure was
& IMCOM Programs
The first step was to analyze both pro-
grams for commonalities and dissimilari-
ty. Once the combined program elements
were identified, the next step was to apply
kaizen protocols to the two safety pro-
gram elements, eliminate paternal twins
and combine the remaining services into
the appropriate IMCOM SSPs.
Early on, the decision was made to
create a predictive front end to the six
sigma design package going beyond iden-
tifying and fixing problems. This system
was to get upstream to
the fundamental deci- By applying the
sion-making process
and become more basic principles of
active than reactive. lean six sigma and
This meant the stan-
dard DMAIC kaizen and by using
Figure 2 Application process was not
applicable and it
design for six sigma
of Kaizen Protocols was replaced with techniques, align-
DFSS. By using
DFSS, the design ment of the com-
analysis ensued peting safety
using the identify,
design, optimize processes into a
and validate
(IDOV) process.
cost-efficient man-
DFSS focuses on agement program
preventing problems
instead of just fix- and office structure
ing them. Using was conducted.
DFSS, the auditor is
able to proceed further upstream to rec-
ognize design decisions that affect the
quality and cost of all subsequent
activities necessary to build and deliver
the product or service.
Figures 1, 2 (left) and 3 (p. 22),
illustrate the logic flow of the begin-
ning (two variant DNA strains/
The premise was that Safety VIσ would combine programs), the application of kaizen
essential TRADOC (or other senior mission command- protocols and the end result of a hybrid program consist-
er), IMCOM and DOD/DOL voluntary protection pro- ing of common and unique variant DNA strains.
gram processes and associated industrial system metrics Generation 3 (Figure 4, p. 22), illustrates the conver-
while eliminating process duplication (kaizen) and with- sion of remaining TRADOC and IMCOM process/SSP
out increasing the expenditure of limited resources into a hybrid system. The systems presented qualified
beyond the current or previous fiscal year level provided. and quantified pro cesses blended with DOL/DOD VPP.
By applying the basic principles of lean six sigma and To quantify the system, processes were analyzed and
kaizen and by using design for six sigma techniques, various definitions and assumptions were documented.

Figure 3 Merging of as the basis for identifying and quantifying process
opportunities and the associated defect versus nondefect,
Program Common Elements a six sigma matrix was created illustrating the processes
as a definitive data set comprising one safety system—
the new hybrid system or division comparison. The
matrix/table provides a six sigma ranking based on the
delta between the sum of the possible process opportuni-
ties and the identified defects per subelement/process
(Figure 5).
With the processes identified and metrics assigned, it
is a matter of selecting those processes that support the
individual SSP and illustrate opportunities and defects
related to OIP/CIP and VPP audits. Additionally, the
metrics must support the higher-level performance meas-
ure reviews established by HQIMCOM and other
MACOMs. A process is defined as an SSP consisting of
subprocesses/tasks while statistical process controls,
defined as metrics, illustrate the variance of the activi-
ties/actions performing the process (subprocesses, tasks)
IAW with established conditions and standards defined
as opportunities.
Process (performance) indicators are standardized,
Figure 4 Final Hybrid assigned to and will represent the individual process
With DOD/DOL OSHA VPP DNA throughout the analysis.


•planned high-/medium-risk evaluations completed
vs. number of sites requiring evaluation;
•identified RAC I and II safety hazards corrected
within 30 days;
•number of job safety analyses conducted vs.
•number of new operational changes that included
hazard analysis and CRM;
•number of safety-related work orders completed in
2 business days.
•number of documented safety briefings conducted;
•number of army traffic safety training program stu-
dents completed versus dropouts;
The fundamental definition is that of defect—what con- •number of new employees completing new employee
stitutes a defect and does not. safety orientation;
A defect or process defect is defined as an ORI/CIP •number of commanders completing commander’s
auditor finding or observation. A nondefect is defined as certification training;
satisfactory or commendable annotation by the auditor. •number of additional duty safety officer/collateral
There is no reference to the quality of the annotation—it duty safety officer completing certification training.
is either a defect or not.
Numerically, a defect is assigned a value of one. That POLICY/PROGRAM PROCESS
is, there is a one-to-one association to ORI and CIP eval- (LEADERSHIP/MANAGEMENT)
uation topic. (1 topic equals 1 defect or 1 nondefect •number of organizations’ annual safety goals
opportunity). There are no weighted averages with the achieved;
established processes. •number of organizational army readiness assessment
program (ARAP) and National Safety Council (NSC)
FINDINGS & DISCUSSION surveys completed;
Using the MACOM/activity CIP/ORI evaluation form •number of ARAP/NSC corrective actions implemented;

Figure 5 centage of training completed for staff
who require safety training, percent-
Defect/sigma Data Set Matrix age of new employees who have com-
pleted new employee orientation,
percentage of motorcycle owners who
have completed the basic riders
course/military sports riders course
training, percent of planned high- and
medium-risk safety evaluations com-
pleted, percentage of identified safety
hazards corrected within a set period
of time, percentage of new opera-
tional changes that included hazard
analysis, percentage of safety behav-
ior observations consistent with
Figure 6 expectations, percentage of organiza-
tions’ annual safety goals achieved
KPI/Business Drivers and percentage of position descrip-
tions that outline health and safety

Examples of lagging indicators
include percentage of Garrison
incidents reported, percentage of
Garrison (AF/NAF) SIGCEN Class
A-D injuries reported, percentage of
Garrison (AF/NAF) SIGCEN Class
A-D equipment damage reports,
actual Garrison (AF/NAF) SIGCEN
and contractor OSHA recordable inci-
dent rate (TCIR), actual Garrison
Figure 7 (AF/NAF) SIGCEN and contractor
OSHA days away from work (DART)
Hazard Prevention & Control and actual Garrison (AF/NAF) SIG-
CEN WC claim rate (OWCP).
By using Safety VIσ, Fort Gordon
safety management processes per-
formed at an average 94% compli-
ance with established TRADOC and
IMCOM evaluation criteria for fiscal
year 2008. This equates to a 3.66
sigma. Industrial programs average a
rank between three and four sigma.
Program efficiencies and compliance
increased 36% when compared
•number of organizational safety committee meetings against the FY06 baseline evaluation
conducted; of 59% compliance.
•number of organizational preventive maintenance Applying statistical process controls (SPC) to areas that
events completed. were previously unquantifiable or not even evaluated or
consisted of lagging or “after-the-fact” events (accidents,
LEADING INDICATORS injuries) were now balanced with
Examples of program leading indicators include percent real-time process leading indicators illustrating the health
of reported injuries investigated by installation safety office of the overall safety management process as a summation
division personnel, percentage of identified corrective of the whole and not just a few topics of interest.
actions completed for reported concerns/complaints, per- Safety VIσ has three levels of statistical process

Figure 8 importance. The statistical processes are
directly tied into customer needs and are
Sample Performance Management Review defined as command intent and provision
of SSP.
SSP Metric Using KPI & Six Sigma The three levels of importance are
process owner, division/office level and
directorate/command level. The information
provided within the levels is: Why is the
information being provided? Who uses
/reviews the information? What is the infor-
mation telling?
The process owner level contains the
detail of the process analysis. It shows not
only the delta between opportunities and
defects (basis for six sigma), but also the
variation within the process (statistical
process control data). Statistical process
control data illustrate how the process is
operating by tracking normal vs. variation
and allows the process owner to correct to
meet the target opportunity level. Variations
are illustrated through the use of statistical
process control charts (generally in the
form of Cp/Ck charts).
In the division level, there is overall visi-
bility of the composite of the target process-
es, which are rolled up into a subsystem
series of charts and the individual pro-
Figure 9 cesses are combined into and compared
to the MACOM ORI/CIP checklist sec-
Sample Basic Motorcycle Rider Course tions. This is a composite check of the
Statistical Process Control Chart, FY08 processes performed within the MACOM
division. Here variations are identified
across the division subsystem and correc-
tions are made.
In the directorate/command level,
there is overall visibility of the division
and the process owner composites
compared to the MACOM OIR/CIP
checklists. This is a composite check
of the processes performed within
the MACOM divisions compared
The data presented here are reduced
to four vital areas comprising 15 KPIs
and a frequency matrix, which is passed
on to senior leadership in various forms,
one of which is illustrated in Figure 8.

Performance measurements (PMs)
illustrate the key process and process
indicators supporting the formula associ-
ated with the IMCOM performance
management review (PMR) SSP metric.
KPI and PI are used to define the output

Figure 10
Program Evaluation, Six Sigma Data

measure of the PM SSP metric using common deriva- health of the underlying subsystems (MACOM Division)
tives—delta installation and the MACOM-established and individual processes.
defects per million opportunities (DPMO). DPMO delta is comparable across all MACOM/HQ
Process indicators illustrate the variance of the indi- elements regardless of ORI/CIP parameters. In creating
vidual process/SSP at the installation, division and defects per opportunity, opportunity is a part while defect
process level supporting the results of the individual is any nonconformance to the part specifications, regard-
PMR SSP metric and answer the question, “Why?” less of how many processes are applied to each part. A
Process indicators are both textual and visual repre- part is defined as a process indicator. A defect is a defect,
sentations of the variance between the units of opportu- which is compared to the unit of opportunities for suc-
nities and the defects identified during a specific time cess. There are no weighted defects. All rankings are yes
period judged against the acceptable defects per million or no, successful or defective, go or no-go. For the pur-
opportunities established by MACOM. poses of this article, a part is defined as a process indica-
When compared to DPMO, process indicators pro- tor (requirements driver).
vide a visual picture of the health of the individual per- An example is the comparisons between the Mission
formance measurement/system, which illustrates the and Garrison Division of the Fort Gordon Installation