Nauman Rasheed

EXECUTIVE SUMMARY ..................................................................................................2 1.1. Objectives ...............................................................................................................4 1.2. Method Used...........................................................................................................4 1.3. Report Format ........................................................................................................6 2. INCIDENT FACTS ......................................................................................................7 2.1 Background.........................................................................................................7 2.2 Incident Summary ..............................................................................................9 2.3 Sequence of Events & Other Information ....................................................... 10 2.4 Technical Analysis ............................................................................................ 12 2.5 Possible Contributing Factors .......................................................................... 13 2.6 Some Basic Facts about Vehicle & Driver Capabilities .................................... 13 2.7 Could the Accident be avoided?....................................................................... 14 3. ROOT CAUSE ANALYSIS .......................................................................................... 15 3.1 TYPE OF EVENT ................................................................................................. 15 3.2 IMMEDIATE / DIRECT CAUSES ........................................................................ 15 3.3 BASIC/ROOT CAUSES....................................................................................... 15 4. RECOMMENDATIONS ............................................................................................. 17 EXECUTIVE SUMMARY The accident happened with car AGZ 845 on 14th July 2005 at about 9:30 hours at Maraka, 12.4 kilometers from Thokar Niaz Beg on Lahore-Multan highway. Mohammd Iqbal was on steering and had picked Nadeem, Mansoor and Shoib from their residences and car was on way to Walls Factory. The car speed was around 70 kilometer per hour in the 100 kilometer per hour zone. There were two pedestrians standing near the 2½ feet road carriage separating wall, apparently engaged in conversation. The driver had spotted the pedestrians from some distance. One of the pedestrians, a 12 years old boy named Suhail, sharply turned and ran to cross the road when the car was about 3-5 meters away. The car collided with the boy. Driver applied brakes. The boy was projected into air, fell back on the car bonnet, and rolled down the car which was stopping but yet moving. The car passed over the boy and stopped a distance from him. Unilever managers took charge of the situation and transported the boy to a hospital. The boy died either before or during transportation. He bled from the mouth and from a cut on the head. The boy was pronounced dead by the doctor. The car occupants were unharmed. Car front grill and bonnet were damaged. Vehicle maintenance did not have a role in the incident as vehicle was found sound. Driver fatigue did not seem to be a contributing factor though on the previous night his duty-off time was 22:30 Hours. Driver was apparently in good health. Two drivers I met and other Unilever officers I interviewed were clear on importance of road safety. Their attitude to safety was very good. Unilever has systems and processes in place for safety including policies, guidelines, training, risk evaluation, standards but they are not tailored to adequately address road transport safety. Other basic/root causes include lack of specific knowledge and skills in defensive driving practices that could have enable d the driver avoid this accident: The collision could be avoided as follows: 1. The boy and companion were visible from a distance. Being engaged in conversation put them in higher risk and first option was to horn and get their attention. In this case the driver could have maintained the car speed. 2. In absence of a positive response, it was essential to continue reducing speed and repeat warning with a target to approach them at a speed stoppable within three seconds of travel. 2|Page There is a need to start raising driving standards at Unilever: (1) Top Management & leadership needs to formulate specific driving policies and provide support for raising driving standards by addressing these four areas: management of drivers, vehicle standards, management of journeys and, road transport health & safety, (2) management responsible for supervising transport activities needs to be trained in implementing driving standards, (3) ongoing defensive driving training and refresher training need to be bolstered by ensuring its quality, extending its reach also to management and supervision so they can properly monitor driving behavior even when not engaged themselves in driving. (4) a communication program which is in synchronization with ongoing training can help raise standards quickly. Specific recommendations for Walls Factory include defensive driving for all drivers, vehicle supervisor and management, specially, Administration Manager and Safety Manager, daily tool box meetings with the drivers, encouraging drivers to report Potential Incidents, Hazard Route Mapping of the route, factory-wide safety communication on lessons learned, and monitoring driver fatigue and not penalizing the driver for this accident For prioritizing to implement driving standards, recommendations include:  Professional drivers and employees with high exposure (25,000 km/year)  Employees required to travel on highways and high risk routes  Employees required to travel on motor-cycles and small vehicles  Operations involving higher incident rates 3|Page 1. INTRODUCTION 1.1. Objectives Objectives of this accident investigation as agreed with Unilever are: 1. Independently investigate to find out the immediate and root-causes of the accident 2. Recommend actions to prevent recurrence As agreed, the objective of investigations is not to find faults with people but rather to identify improvement opportunities. 1.2. Method Used Information was gathered as follows: 1. Sabahat Arshad provided the initial details (15 July) 2. Shoib was interviewed 3. Driver (Iqbal) was interviewed (16 July) 4. Vehicle was inspected for damages 5. Vehicle braking efficiency was determined by following a standard procedure and measuring the tyre marks on the road 6. Road conditions were observed, photographed and logged between Kalma Chowk and the factory 7. Accident site was inspected – tyre marks were not found due to the rains which followed after the accident 8. Eye witnesses of the accident were found who helped identify the locations – (where the boy stood before crossing the road, where hit, where he lay on the road, where the car was parked after stopping) 9. Measurements of the road and identified locations were taken and used to estimate the vehicle speed and establish other facts about driver actions 10. Nadeem and Mansoor were interviewed 11. Owais was interviewed on telephone 4|Page 12. Root-Cause Analysis was done to reach the conclusions and recommendation’s [Please see Appendix I: Who is Who] Click link below C:\Documents and Settings\Aslam\My Do 5|Page 1.3. Report Format Chapter 2 establishes the critical facts of the accident to answer the question ‘what happened?” It also explains what actions could have the potential of effectively preventing this accident. Chapter 3 answers the question ‘why it happened?” and then identifies the immediate and root causes of the incident in a format used at Unilever. Chapter 4 lists recommendations on what actions, systems and processes are required to put sound driving standards in place at Unilever Pakistan. There are several Appendices and are provided as imbedded files in this document. The icons need to be clicked to open these files. 6|Page 2. INCIDENT FACTS 2.1 Background Car Pool & Road Exposure Walls factory has a pool of four cars primarily for transporting officers between their residences and the workplace. The cars are also used for pick and drop at the airport and to perform other chores within Lahore. Four drivers and a supervisor operate the fleet. The supervisor daily checks the cars for fitness using a check-sheet. The records are kept. Supervisor also acts as a spare driver when one of the drivers is on leave. The pool is managed by Owais Akmal. Approximate road exposure of the four cars is around 20,000 – 25,000 kilometers per month. Route & Roads The daily journey routes involve two distinct sections: (1) Lahore city area, mostly Defence, Cantonment, Gulberg, Johar Town and adjoining areas and, (2) section of Lahore-Multan highway starting from Thokar Niaz Beg and culminating at the Walls Factory. [Please see Appendix II: Journey Route] Click link below C:\Documents and Settings\Aslam\My Do Roads within Lahore city are well developed but not described here as normal city driving is involved. The accident occurred in the second part of the journey route, involving highway driving in an environment of elevated risks. This section of the route is described below. Lahore-Multan Road, commonly called Multan Road is actually part of National Highway N-5 which runs southward to Karachi. The section of the road in question is a goodquality, two-carriage highway. From Thokar Niaz Beg to the Walls factory, the carriages are separated by three types of constructions: (a) 5 feet separating wall, (2) 2½ feet separating wall or, (c) islands. At places, there is a level difference between the carriages and there is no separating structure. Walls are an important safety feature of the highway often breached by the pedestrians. The separation at the site of the accident is the 2½ feet wall. To facilitate pedestrians, there are openings in the wall. 7|Page There are places to allow vehicles take U-turns and at such places the walls are tapered to allow better view of the other side. Both lanes are 12 feet wide. There is a 7 feet shoulder with the left lane and 2 ½ feet separation distance between the separating wall and the demarcation line of the right lanes. [Please see Appendix III: Road Features] Click link below C:\Documents and Settings\Aslam\My Do The road is asphalted with a well traveled smooth surface. However the road is not as yet polished which occurs after long and heavy usage. There are two speed zones. For light vehicles, the limits are 70 and 100 kilometers per hour. The lower limit zones are meant for populated areas but one can find within 100 km/hr zones, areas which have presence of pedestrians. The site at which the accident occurred is one example. Good quality road signs are posted. At some places there are duplicate road signs of two different designs. Speed limits and warning signs are regularly posted both in English and Urdu. Traffic A mixture of vehicles plies on the road including cycles, motor-cycles, cars, vans, buses, tractors and trucks. There are lots of pedestrians using the road. Populated places have people on the road, waiting, walking or crossing it. Mostly of working age but a good many number of pedestrians are children. In addition to crossing places provided, they cross the road from anywhere. Jumping the shorter wall is very frequent while one can also expect people scaling the 5-feet wall to cross to the other side. I did spot several tractors but did not see any farm animals during my two hours on the road. Due to agricultural use of the surrounding area, there also would be animals crossing the road. This section of the highway is not monotonous. Visual and traffic variations occur frequently necessitating continuous adjustments of speed, position and maneuvering. 8|Page 2.2 Incident Summary Date & Time : 14 July 2005, 09:30 Hours (approximate) Place: 12.4 kilometer from Thokar Niaz Beg on Lahore-Multan Highway (N-5) Vehicle: AGZ-845, Toyota Corolla Model 2004 Vehicle Occupants: Driver: Mohammad Iqbal Front Passenger: Mansoor Lodhi Back-seat (left): Nadeem Akbar Khan Back seat (right): Shoib Third Party (Pedestrian): Suhail Light & Weather Bright and dry Accident Description Following accident description is based on interviews, evidence of witnesses, on site data, car brake performance data and technical analysis of the event presented in other sections of the report. “The car was traveling on the inside lane at estimated 70 kilometer per hour in the 100 kilometer per hour zone. There were two pedestrians standing near the 2½ feet road carriage separating wall, apparently engaged in conversation. One of the pedestrians a 12 years old boy sharply turned and ran to cross the road and reached middle of the lane when the car was about 3-5 meters away. The approaching car collided with the boy. Driver applied brakes. The boy was projected into air, fell back on the car bonnet, and rolled down the car which was in the process of stopping but yet moving. The car passed over the boy and stopped a distance of around 11 meters from him. The car was still in the inside lane but had drifted towards the center. The driver moved the car to the road shoulder. Two of the three car passengers took charge of the situation and transported the boy to a hospital. The boy died either before or during transportation. He bled from the mouth because of internal injuries and from a cut on the head. Cut on the head was probably caused by fall on the road. The boy was pronounced dead by the doctor. The car occupants were unharmed. Car front grill and bonnet were damaged.” 9|Page 2.3 Sequence of Events & Other Information ITEM # TIME 1 2 3 1 7:15 2 7:50 3 4 5 8:10 8:15 8:30 8:50 6 7 EVENT/SITUATION Before the Incident (Previous Days) Driver has the routine of going to sleep before mid-night and waking up at round 6:00. He reaches the Guest House where the car is parked at around 7:15. On previous day (13th July) his duty ended at 22:30 at Guest house after he dropped an officer at the airport. He was home at 23:00 and went to sleep at 00:15. I was well rested Before the Incident (day of the incident) Driver reached Guest House in Defence SOURCE Iqbal Iqbal Iqbal Iqbal (Driver) Reached Nadeem’s residence (Askari Flats, Kalma Iqbal Chowk) Left Nadeem’s residence Iqbal Picked Mansoor Lodhi (Johar Town) Iqbal Picked Shoib Iqbal Picked Mansoor and Shoib Nadeem, Mansoor Car fueling (Thokar Niaz Beg) Iqbal We were around ten minutes later than usual Shoib We were in time Iqbal Accident Iqbal Between 9:00 and 9:15 9:10 Accident Nadeem, Mansoor The Incident Speed was 80-85 Speed was 70-80 Iqbal Nadeem, Mansoor Car was in the right lane for quite some time Iqbal, Nadeem, Mansoor Traffic was thin; vehicles in front and behind were far Iqbal, away Mansoor Nadeem I had seen the boy and a companion apparently Iqbal engaged in conversation The boy moved all of a sudden, when car was 10-15 Iqbal feet away (8 feet – Shoib) Immediately applied brakes Iqbal Car hit boy who went up in the air and fell back on the Iqbal 10 | P a g e bonnet; fell on the road when car slowed down Car went over the boy 9:40 Iqbal, Shoib, Nadeem, Mansoor Car stopped in about middle of the road, I moved it to Iqbal the shoulder and parked Car was around 10-15 meter away from the boy Shoib Post Incident Driver panicked and suggested fleeing the scene Shoib People had gathered around and moved the boy to the Shoib, edge of the road. Nadeem and Shoib talked to people Mansoor, and explained it was important to reach hospital. They Nadeem carried the boy to the car, took one area elder along. Called Motorway Police, described the event and asked about the nearest medical help. They were directed to a clinic in Choong and later asked to reach Ali Hospital in Thokar Niaz Beg which was informed in advance. Doctor present immediately took the boy inside, checked and pronounced him dead. Reached hospital Iqbal Shoib interacted with boy’s parents, community and Shoib police. Parents decided not to register a case with the police. Shoib attended the funeral and donated Rs 10,000 to help pay funeral expenses. Critical Information The speed zone was 100 km/hour. Pedestrians were standing to cross the road but engaged perhaps in conversation. Driver the car kept straight only with a slight shift to the left. Questions (later answered in the report) Was there a pressure on the driver to reach early? Was the driver fatigued? What was the speed before the driver spotted the boy moving in front? Why didn’t the driver horn to warn the pedestrians though he had spotted them engaged ? Why didn’t the driver have the opportunity to swerve car to avoid the collision? Could the collision be avoided? 11 | P a g e 2.4 Technical Analysis Car Braking Performance The car had good braking performance confirmed by two experiments done on a similar road under a standard procedure. Assuming the speed mentioned by the driver and passengers (70-80 km/hr), the stopping distance required is between 35-44 meters. [Please see Appendix IV: Brake Performance] Click link below C:\Documents and Settings\Aslam\My Do Car Speed From the witnesses’ evidence at the accident site, the distance between the location of collision and location of vehicle stopping is around 40 meters. Allowing around 5 meters for moving the car from stopping position to final parking position, the braking distance comes to around 35 meters provided we take the point of impact also as the point of start of braking. This gives a reference point of 70 km/hour at the time of impact. If speed was in excess of 70 km/hour, the braking point has come before the impact. If speed was lower than 70 km/hour, then the braking point has come after the point of collision. [Please see Appendix V: Six Stages of the Accident] Click link below C:\Documents and Settings\Aslam\My Do From driver’s interview, an element of surprise can be deduced. Allowed more time for reaction, the driver could have swerved the car to the left to avoid the collision. From the nature of damage to the car it can be seen that: (a) direction of bonnet crumple at the first point of impact is parallel to the road direction and, (b) place of boy’s fall on the bonnet and subsequently on the road are in line with the initial place of impact. The second collision has slightly shifted to the left side of the bonnet, probably due to the fact that boy was moving toward the road shoulder at the time of impact. The first collision was off-center on the right side. [Please see Appendix VI: Collision Mechanics] Click link below C:\Documents and Settings\Aslam\My Do For estimation, speeds with stopping distances short of 33 meters (3 meters before impact + 20 meters up to the point of boy’s falling on the road + 10 meters car distance from the fallen boy) can be discarded. This gives a best estimate of speed close to 70 km/hour. The speed was within legal limits (posted 100 km/hour), safe otherwise but unsafe to continue in face of the approaching risk. Posted limits are the maximum speed limits only under safe conditions. 12 | P a g e 2.5 Possible Contributing Factors Vehicle maintenance did not have a role in the incident as vehicle condition other than the accident damage was sound. Brake performance has already been described. All seat belts, lights and indicator lights were functioning. Tyres were in good condition. Driver fatigue did not seem to be a contributing factor though on the previous night his dutyoff time was 22:30 Hours. Drivers have a place in the factory for resting. Driver was apparently in good health. His sight and hearing was found normal. Drivers undergo medical check up on hiring and annually onwards. They once have been tested for drug abuse. There did not seem a pressure from passengers or the supervisors to breach speed limits. Two drivers I met and other Unilever officers I interviewed were clear on importance of road safety. Their attitude to safety was positive. However I found drivers and Unilever officers short on knowledge of specific measures that could have avoided this accident. Driver did not horn to warn because he believed it was undesirable (based on previous opinion of some manager or supervisor). Motorway Police conducted two safe driving communication sessions with drivers which the driver attended but could not recollect any instruction relating to the incident situation. There is no record of the session contents. 2.6 Some Basic Facts about Vehicle & Driver Capabilities Avoiding a collision involves capabilities of the driver as well as that of the vehicle. The vehicle can not be swerved or stopped at will. There are physical limitations which can not be overcome by any capability from the side of the driver. Similarly there are limitations of the driver which can not be compensated by any capability of the car. In the incident in question, limiting capabilities in play were: 1. Despite having spotted the boy and his companion from a distance, failure of the driver to anticipate a situation requiring collision avoidance maneuvers well in time. 2. When driver spotted the boy running, the maneuver he performed (brakes) was the right maneuver but, given the distance in front and the car speed, it was not possible to avoid the collision. The speed at that spot was around 70 km/hour. The distance available to complete the brakes was 3-5 meters. It is not possible to complete the braking maneuver safely with this combination of speed and braking distance. 13 | P a g e 2.7 Could the Accident be avoided? Technically, the accident could be avoided by practicing normal safe driving practices and standard defensive driving techniques. Following are two possibilities: 1. The boy and companion were visible from a distance. Since they were not attentive, there was a risk they could create an unsafe situation. First option was to horn and get their attention. In this case the driver could have maintained the car speed. 2. In absence of a positive response, it was essential to continue reducing speed and repeat the warning with a target to approach them at a speed stoppable within three seconds of travel. [Please see Appendix VII: How the Collision Could be Avoided] Click link below C:\Documents and Settings\Aslam\My Do 14 | P a g e 3. ROOT CAUSE ANALYSIS Root Cause Analysis of the incident follows. For complete listing please see Appendix VIII. [Please click link below] C:\Documents and Settings\Aslam\My Do 3.1 TYPE OF EVENT  The car struck the boy at 70 km/hour 3.2 IMMEDIATE / DIRECT CAUSES Substandard Acts  The driver failed to anticipate the potential risk of boy crossing the road  The driver failed to warn the pedestrians in advance  When the boy started to cross the road, the car was at improper speed Substandard Conditions  Pedestrians crossed the road at inappropriate place and without following safe road crossing procedures (Improper Road Condition)  It was not possible to avoid collision, given the improper speed and restricted distance  Driver had inadequate knowledge and skills to safety deal with the hazard 3.3 BASIC/ROOT CAUSES Personal Factors  Unsafe road conditions put extreme demands of concentration and perception on the driver 15 | P a g e  Driver class-room training provided not confirmed to have covered specific collision avoidance procedures, maneuvers and techniques  Defensive driving skills/knowledge assessment, coaching and follow-up not provided to drivers  Management unintentionally condones improper driving conduct because of its level and application of knowledge of specific collision avoidance procedures, maneuvers and techniques, Job / System Factors  Unilever has systems and processes in place for safety including policies, guidelines, training, risk evaluation, standards but they are not tailored to adequately address road transport safety. 16 | P a g e 4. RECOMMENDATIONS 4.1 Main Recommendations As is evident from the findings, there is a need to start raising driving standards at Unilever with initiative coming from the leadership. a. Leadership & Management Top Management & leadership needs to formulate specific driving policies, provide support and resources and ensure management commitment for raising driving standards in the company. The leadership needs get the management trained in driving standards and relevant road transport issues so it is possible for them to monitor performance. The leadership needs to acquire professional help to identify, prioritize and plan improvements in driving standards in following areas: management of drivers, vehicle standards, management of journeys and, road transport health & safety. There has to a process of setting road safety related objectives and targets and performance reviews and audits. b. Driver Training Unilever must ensure that the initial defensive driving training programs and refreshers reach all those who drive on Company business. Those who do not drive but supervise driving individuals also must undergo training so they can provide proper supervision. Management should openly support and participate in such programs. To ensure quality and reliability of instructions, Unilever must develop quality and accreditation criteria for defensive driving training providers. c. Driving Safety Communication In addition to enhancing driving skills, implementing safe driving standards requires a change of attitude and acceptance of idiom and concepts of defensive driving. A communication program which is in synchronization with training can help raise standards quickly. 17 | P a g e 4.2 Other Recommendations a. Wall’s Factory There are three specific recommendations:  Defensive driving training for all drivers, vehicle supervisor and management specially , Administration Manager and Safety Manager  Daily 5-10 minute tool box meetings with the drivers (led by Administration Manager or Safety Manager) focusing on a single operational or safety issue. Records are to be kept.  Encouraging drivers to report (records to be kept) Potential Incidents  Hazard route mapping of the route and communication to all users  Factory-wide safety communication describing the accident investigation findings and lessons learned  Monitoring driver fatigue (keep daily records) using these guidelines:   Daily duty hours not to exceed 12 hours (two exceptions per week, followed by shorter periods the following day)  Daily driving hours not to exceed 9  Continuous driving in one spell not to exceed 2 hours (before taking a rest period of 20 minutes)  One weekly off-duty period of minimum 24 hours Do not penalize the driver (Mohammad Iqbal) for this accident b. Setting Priorities As it takes time to implement standards, priorities should be decided. Following are some of the areas identified during data gathering and discussions:  Professional drivers and employees with high exposure (25,000 km/year) with emphasis on reducing unnecessary road exposure  Employees required to travel on highways and high risk routes; providing them with appropriate skills and vehicles  Employees required to travel on motor-cycles and small vehicles; studying proposals to raise vehicle standards  Operations involving higher incident rates; identifying areas for improvements 18 | P a g e