Incident Investigation Techniques

Fundamental reason for investigating incidents

Prevention of similar future loss In other words – an investigation is a reactive process that should result in proactive improvements to incident prevention measures.

Although reactive, effectively conducted incident investigations allow us to learn from the loss experience in order to strengthen our proactive efforts and prevent future similar loss situations.

In an accident investigation, one tires to obtain answers to the following questions: what happened, why it happened, and how could this have been prevented?

An accident investigation should adopt a systematic approach to identify the factors leading to the accident, and in addition, it should examine what improvements are needed in the work environment and in organizational procedures as well as clarifying the responsibilities of each participant. The use of a systematic approach confers reliability on the investigation and making it possible to describe in a comprehensive manner the course of accident and all factors influencing the accident. In brief, one needs to have rules of conduct for an investigation: who should participate and how to implement the investigation in practice.

After every incident and accident, we should decide what kind of safety measures, guiding, training and information will be needed in the workplace to prevent the same kind of incidents and who should deal with this information in the first place

Who is the primary person for the Investigation?

Supervisors need to be directly involved in the investigation process.

Because

• Accidents directly affect department personnel, equipment, and productivity.
• Supervisor has thorough knowledge of people and conditions.
• Supervisor has direct responsibility for (or at least involvement in) taking corrective action. 

Steps in the Investigation

• Initial response
• Gathering information
• Analyzing the data and determining the causes
• Determining/initiating actions and writing the report
• Follow-up

Initial response

• Taking control of the scene
• Avoiding secondary accidents
• Obtaining medical treatment

Preliminary Information Gathering - At the Scene

Identifying sources of information - Note your surroundings; people present; environmental conditions (light, noise, heat, cold, etc.); position of materials, tools and equipment; anything out of the ordinary

Preserve the scene - Protection of the area from alteration as much as possible, ensure required notifications are made and gather information quickly and completely.

Be a sponge - It is important to distinguish between FACT and OPINION and understand the role BOTH play in the investigation

Depending on the emotional state of those involved - Interview eye witnesses first, then secondary witnesses

Tips on Conducting Interviews

• Interview separately
• Interview in an appropriate place, on-site (if not dangerous or uncomfortable) or in a private area. Offices may appear too much like interrogation/cross examination.
• Put the person at ease - assure them that the mission is "fact" finding to prevent a recurrence.
• Avoid intimidating voice and body language.
• Get the individual's version

1. Avoid interrupting
2. Don't put words in their mouth
3. Don't make judgmental statements like "that was sure a dumb thing to do."

• Don't ask leading questions and avoid yes-no questions
• Give the witness some feedback. Repeat information to ensure understanding and provide a chance for correction. This creates "active" listening on the part of both parties.
• Use visual aids (sketches, digital photos).
• End on a positive note. Thank them for their time and effort. Ask their ideas on how this situation could be prevented in the future. Keep the line open.

Information gathering from other sources

Depending on the situation, other sources of information may be helpful, such as: -

• Training Records
• Maintenance records (repair and PM)
• Safety inspection reports
• JHA, JSA , JSP and MOC documents
• Changes in production schedule, materials, tools and equipment
• Special testing such as Material Failure Analysis
• Drawings and photos

Analyzing the data and determining the causes

1. Immediate causes (symptoms)
2. Basic causes (the why)

"CARELESSNESS" IS NOT AN ACCEPTABLE REASON FOR "WHY" AN ACCIDENT HAPPENED. WE SHOULD ASK "WHY" WAS THE PERSON "CARELESS".

Analysis

• is objective and unbiased;
• identifies the sequence of events and conditions that led up to the adverse event;
• identifies the immediate causes;
• identifies underlying causes, ie actions in the past that have allowed or caused undetected unsafe conditions/practices;
• Identifies root causes, (ie organizational and management health and safety arrangements – supervision, monitoring, training, resources allocated to health and safety etc).

Techniques for analysis

There are many tools and techniques for structuring the investigation, analyzing adverse events, and identifying root causes. – It is for you to choose which techniques suit your company. These techniques are simply tools, not an end in themselves.

For large, complex or technically demanding investigations, these techniques may be essential in determining not only how the adverse event happened, but also what, were the root causes.

However, provided a methodical approach with full employee participation is adopted, a less complicated approach, such as that set out in this publication, will be appropriate.

Report Writing

• Be specific – avoid generalities
• Avoid legal opinions
• Avoid extreme language
• Watch your ADJECTIVES
• Use familiar terminology

SUMMARY

Determine what “really” happened rather than try and prove what we “think” happened.