Explosive Incident Investigation

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Explosive Incident Investigation
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Part One
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Part One Introduction of Investigation Principles
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• The aim of ammunition, mine, and explosive
  incident investigation is to gather evidence to
  establish
• What happened
• Why it happened
• What can be done to minimize the risk of it
  happening again

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• It is not the function of an explosives incident
  investigation to apportion guilt

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• Each incident starts at a point where 'normal'
  behaviour is interrupted

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• The immediate reaction to the incident is always
  shock and surprise
• Followed quickly by a mixture of guilt and anger
  as opinions are formed about the cause of the
  incident

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• Mine incidents can generate immediate government
  and media interest
• This can lead to further speculation about the
  'cause' of the incident

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• It is therefore vital to initiate an
  investigation as soon as possible to establish
  the facts

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The Investigation

• The aim of the Investigation is to gather the
  facts about the incident
• What happened?
• Who was involved?
• Where and when did it happen?

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• The investigation should also assess whether the
  immediate action drills carried out were
  sufficient.
• This should include whether appropriate medical
  and other safety cover was in place.

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• mine incident investigations should be able to
  furnish any subsequent Board of Inquiry with the
  information necessary to produce objective
  findings and thus modify behaviour.

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• In order to prevent internal conflict, the
  information necessary for the investigation to
  complete its role in this process should be set
  out in organisational Accident Investigations
  Procedures

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• Other important points for the investigation are
• Assume the area of the incident is mined until
  proven otherwise
• Ensure access to the site is possible
• Ensure medical backup is available for the
  investigation
• Minimize number of visits to the site

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The Board of Inquiry

• The Board of Inquiry is intended to deliberate on
  the findings of the investigation
• The primary aim is to determine what should be
  done to prevent repetition of the incident

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• Once it is clear from the investigation what
  happened, there are only 2 real questions that
  have to be asked in order to meet the aims of the
  inquiry process.

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• Were established procedures adequate to prevent
  this incident?

No
AMEND PROCEDURES
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• Were established procedures adequate to prevent
  this incident?

Yes
Was the training and promulgation of the
procedures adequate?
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Were the training and promulgation of the
procedures adequate?
No

• Improve training and promulgation

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Was the training and promulgation of the
procedures adequate?
Yes

• Consider other factors (curiosity, misadventure)

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Sequence of Events

• There is a clear sequence of events
• Incident
• Immediate action
• Investigation
• Board of Inquiry
• Modification of Behaviour

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Part Two
Classification of Explosives Incidents
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• All incidents can be categorised in several
  different ways. These are

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Part Three

• Analysing the Cause of the Incident

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• The aim of this part of the presentation is to
  provide more detail on the analysis of the cause
  of mine incidents

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• One of the most common causes of mine incidents,
  particularly among civilians, is that the
  casualty was 'unaware' that there was a mine
  threat.

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• Another cause is being lost
• This may include situations where vegetation has
  overgrown temporary signs or marking

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• A further common cause amongst civilians,
  particularly the young, is 'misadventure'...
• This is when the casualty knows that the area may
  be mined, but willingly takes the risk. This may
  be due to bravado, such as 'playing chicken' or
  taking bets

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• It can also involve fatalism from those who feel
  they have no choice, due to economic imperatives.

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• Another possible cause of mine incidents is
  'operating in areas reported as clear'.
• This is most likely due to faulty passage of
  information.
• Precise marking drills and reports should help
  eliminate the chances of this happening

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Demining Incidents

• Although these causes are also possible among
  mine clearers, there are a further set of
  possible causes that specifically apply to those
  engaged in mine clearance operations.

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• In order to establish a correct perspective of an
  incident involving mine clearance personnel, it
  is vital that the Board of Inquiry understands
  what contractual requirements have been set and
  what SOPs are being followed.

SOPs
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• There is the possibility that the 'wrong' drill
  was selected.
• For example, using a mine detector in a heavily
  metal-contaminated environment

• Even if the mine detector was then operated
  perfectly by the operator, this would be the
  wrong drill.

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• The classification of 'wrong drill' should not be
  confused with the term 'error in drill'.
• An 'error in drill' is when the correct drill is
  chosen, but done badly.

• An example of this would be to fail to check the
  batteries in a mine detector before using it.

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• It is possible - but very unusual - that
  equipment failure may be a cause.
• The Investigation should ask "Was specified
  periodic confidence testing carried out?"
• If not, then the incident should also be
  classified as an 'error in drill'

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• The 'unknown' category should only be used once
  all of the other potential causes are eliminated.
• "Suspected Remining" falls into this category.
• (But Investigation often reveals personnel were
  working in ground incorrectly regarded as clear)

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• To sum up, A process of elimination should be
  used to classify the cause of the mine incident.
• a Board Of Inquiry can use the results of an
  investigation to identify the most appropriate
  modification in procedures.
• A thorough mine incident investigations process
  should reduce the risk that the wrong conclusions
  are drawn from a mine incident.

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Any Questions?