1. Incident at… Start

2. Index 1.Incident Description and OutcomeIncident Description and Outcome 2.General InformationGeneral Information 3.Main findings from investigationMain findings from investigation – Solutions according to the 'simplified' table Solutions according to the 'simplified' table – Additional actions suggested by Hearts and Minds Program Additional actions suggested by Hearts and Minds Program – Actions taken ('simplified') Actions taken ('simplified') 4.Summing Up…Summing Up… – First-time offence First-time offence – Second-time offence Second-time offence Continue

3. Incident description A pick up driver along with three passengers were on their way to the base for crane reparation work. About 80 km from the destination place the driver (who was allowed only 2,5 hours rest the previous night) fell asleep and the vehicle hit the mountain on the left side of the road. After the impact the vehicle rolled and landed on its roof about 80 meters from the impact point. None of the passangers were wearing their seatbelts Outcome All the vehicle occupants were injured. The rear side passenger sustained major head injuryand after few months in coma passed away. The vehicle suffered extensive damage. Continue Index

4. General Information Main cause Driver fell asleep behind the wheel while driving Main findings from investigation Driver had only 2.5 hours of sleep Journey Manager failed to challenge/recognize driver’s fatigue Driver failed to apply the Empowerment to Stop Driver failed to tell the passengers to wear seatbelt Driver was trained in Defensive Driving but not on organisation approved course. Journey Manager was not trained. Summing Up… Index

5. OffenceFirst OffenceSecond OffenceThird Offence Tampering with safety devices Summary Dismissal Driving under the influence of alcohol Summary Dismissal Driver or passengers without seatbelt Final Warning to DriverDismissal of Driver Excessive speedingFinal WarningDismissal Overtaking in dustFinal WarningDismissal Driving without a valid ('simplified') driving licence Warning LetterFinal WarningDismissal Using GSM while drivingWarning LetterFinal WarningDismissal Driving a company vehicle without a valid RAS sticker or with significant and obvious deficiencies in the roadworthiness Warning LetterFinal WarningDismissal Summing Up… Index

6. Main findings from investigation Driver had only 2.5 hours of sleep Journey Manager failed to challenge/recognize driver’s fatigue Driver accepted the assignment knowing he was unfit to drive Driver failed to tell the passengers to wear seatbelt Driver was not trained in the approved Defensive Driving course. Journey Manager was not trained. 'simplified' Suggestions Hearts and Minds Suggestions Back to General information Summing Up… Index

7. OffenceFirst OffenceSecond Offence Third Offence Driver failed to tell the passengers to wear seatbelt. Driver or passengers without seatbelt Final Warning to DriverDismissal of Driver Journey Manager failed to challenge / recognize driver’s fatigue Not addressed by the 'simplified' approach Driver accepted the assignment knowing he was unfit to drive Not addressed by the 'simplified' approach. Journey Manager was not trained. Not addressed by the 'simplified' approach. Driver was not trained in the approved Defensive Driving Course Final Warning to DriverFinal WarningDismissal Driver had only 2.5 hours of sleep Not addressed by the 'simplified' approach. Solutions according to the 'simplified' table'simplified' table Actions taken Back to Main Findings Back to General information Incident description Summing Up… Index

8. Offence Journey Manager failed to challenge/recognize driver’s fatigue Company to ensure all Journey Managers are trained Driver accepted the assignment knowing he was unfit to drive Ensure all drivers go for the Defensive Driving Course Driver failed to tell the passengers to wear seatbelt.Brief all Drivers and use the Driver involved on the importance of ensuring all passengers wear seat belts and also explain to them the consequences for non-compliance to the rule Journey Manager was not trained.Company to ensure all Journey Managers are trained Driver was not trained in the approved Defensive Driving Course. Ensure all drivers go for the Defensive Driving Course Driver had only 2.5 hours of sleep Emphasis the importance of having a good night’s rest prior to any journey. Immediate Actions ('simplified') Back to Main Findings Back to General information Incident description Hearts and Minds Suggestions Summing Up… Index

9. Additional actions suggested by Hearts and Minds Program Description of a behaviour BehaviourConsequences for the individual Consequences for the Managers of the individual Journey Manager failed to challenge / recognize driver’s fatigue MistakeTrainingCoaching.in Error Management and Competence Management. Driver accepted the assignment knowing he was unfit to drive (Routine) Situational violation Coaching on the need to speak- up when the rules cannot be followed and to stop the job until it can be done safely. Verbal Warning Coaching on Managing Rule Breaking and a Written Warning If this type of situation has occurred before performance appraisal is affected for not demonstrating commitment to rule compliance. Final Warning Next Back to Main Findings Back to General information Incident description Summing Up… Index

10. BehaviourDescriptionConsequences for the individualConsequences for the Managers of the individual Driver failed to tell the passengers to wear seatbelt. Lapse Coaching on what influences the occurrence of lapses and the importance of reporting them. Coaching in Error Management. Driver had only 2.5 hours of sleep (Routine) Situational violation Coaching on the need to speak-up when the rules cannot be followed and to stop the job until it can be done safely. Verbal Warning Coaching on Managing Rule Breaking. If this type of situation has occurred before performance appraisal is affected for not demonstrating commitment to rule compliance. Final Warning Journey Manager was not trained. Organisational Violation Coaching on the need to speak-up when the rules cannot be followed and to stop the job until it can be done safely. Verbal Warning Coaching on Managing Rule Breaking Final Warning If this type of situation has occurred before, there should be a formal discipline for reckless supervision in creating a culture that encourages this behaviour. Dismissal Driver was not trained in the approved Defensive Driving Course. (Routine) Situational Violation. Coaching on the need to speak-up when the rules cannot be followed and to stop the job until it can be done safely. Verbal Warning Coaching on Managing Rule Breaking. If this type of situation has occurred before performance appraisal is affected for not demonstrating commitment to rule compliance. Final Warning Back Back to Main Findings Back to General information Incident description Summing Up… Index

11. Definitions BACK

12. Journey Manager failed to challenge/recognize driver’s fatigue because, … 1.… he believed that the driver was sufficiently rested and therefore did not need to intervene. MISTAKE BACK Back to Main Findings Back to General information Incident description Summing Up… Index

13. Driver accepted the assignment knowing he was unfit to drive because, … 1.… he was afraid to loose his job. SITUATIONAL VIOLATION BACK Back to Main Findings Back to General information Incident description Summing Up… Index

14. Driver failed to tell the passengers to wear seatbelt because, … 1.… he was so tired he simply forgot. LAPSE BACK Back to Main Findings Back to General information Incident description Summing Up… Index

15. Driver had only 2.5 hours of sleep because, … 1.… SITUATIONAL VIOLATION because he did not feel he had any other choice than driving while he was not sufficiently rested. Back to Main Findings Back to General information Incident description BACK Summing Up… Index

16. Journey Manager was not trained because, … … organisation did not took proper care to train their journey managers to e.g. save some costs. ORGANISATIONAL OPTIMISING VIOLATION, ROUTINE VIOLATION BACK Back to Main Findings Back to General information Incident description Summing Up… Index

17. Driver was not trained in the approved Defensive Driving Course because, … … organisation did not took proper care to make sure all the drivers took an approved course. ORGANISATIONAL OPTIMISING VIOLATION Back to Main Findings Back to General information Incident description BACK Summing Up… Index

18. Summing up… With the assumption of first-time offence Consequences for the driver Consequences for the Journey Manager. Consequences for the General Manager 'simplified' Table Final Warning Not addressed by the 'simplified' approach. Hearts and Minds Table Coaching on the need to speak- up when the rules cannot be followed and to stop the job until it can be done safely. Coaching on how to spot errors, what influences the occurrence of lapses and the importance of reporting them. Training Verbal Warning Competence development/ coaching. Coaching on the need to speak-up when the rules cannot be followed and to stop the job until it can be done safely. Training Verbal Warning Coaching in Error Management and Competence Management. Coaching on Managing Rule Breaking together with team. Written Warning Final Warning Index Next

19. Summing up… With the assumption of second-time offence Consequences for the driver Consequences for the Journey Manager. Consequences for the General Manager 'simplified' approach Dismissal of a driver Not addressed by the 'simplified' approach. Hearts and MindsTable Training. Coaching on the need to speak- up when the rules cannot be followed and to stop the job until it can be done safely. Coaching on how to spot errors, what influences the occurrence of lapses and the importance of reporting them.. Verbal Warning Competence development/ coaching. Coaching on the need to speak-up when the rules cannot be followed and to stop the job until it can be done safely. Training Verbal Warning Dismissal Index Back