Incident investigation techniques

1. INCIDENT INVESTIGATIONTECHNIQUES
CharacteristicsOf AnIncident:
•Unplannedevent
•Multiple factorsinvolved –Unsafe behavioursand/orunsafe physical conditions
•Incidentsresultinsome formof loss
– people,property,environment, Process
FUNDAMENTALREASON FOR INVESTIGATINGINCIDENTS:-
Preventionof similarfuture loss
In otherwords – an investigationisareactive processthatshouldresultinproactive improvements
to incidentpreventionmeasures.
Althoughreactive,effectivelyconductedincident investigationsallow ustolearnfromthe loss
experience inordertostrengthenourproactive effortsandpreventfuture similarlosssituations.
PRIMARY PERSON RESPONSIBLEFORTHE INVESTIGATION
Personal interest –accidentsdirectlyaffectdepartmentpersonnel,equipment,andproductivity.
Knowledgeof peopleandconditions.Responsibilityfor(orat leastinvolvementin) takingcorrective
action.Demonstratescontrol.
MANAGERS
 A majorlossor a highpotential incident
 The circumstancescross intoothersupervisors'areas
 The remedial actionshave abroad scope or
 significantcosts
STAFFPERSONNEL
 Whentheycan serve as advisorstothe investigators -buttheyare notthe prime investigator
 Special knowledge areassuchassafety,industrial hygiene,engineering,purchasing,
maintenance,human resources,etc.
STEPS IN THE INVESTIGATION:
• Initial response
• Gatheringinformation
• Analysingthe dataanddeterminingthe causes
• Determining/initiatingactionsandwriting the report
• Follow-up
INITIALRESPONSE:- Takingcontrol of the scene
Avoidingsecondaryaccidents
Obtainingmedical treatment
PRELIMINARYINFORMATION GATHERING- AT THE SCENE

2. Identifyingsourcesof information
Note yoursurroundings;peoplepresent;environmental conditions(light,noise,heat,cold,etc.);
positionof materials, toolsandequipment;anythingoutof the ordinary
Preserve the scene
Protectionof the areafrom alterationasmuchas possible,ensurerequirednotificationsare made
and gatherinformationquicklyandcompletely.
Be a sponge
GATHERING INFORMATION:-
It isimportantto distinguishbetweenFACTandOPINION andunderstandthe role BOTHplayinthe
investigation
Dependingonthe emotionalstate of those involved - Interview eye witnessesfirst,thensecondary
witnesses
TIPSON CONDUCTINGINTERVIEWS:-
Interviewseparately
• Interviewinanappropriate place,on-site(if notdangerous oruncomfortable)orina private area.
Officesmay appeartoomuch like interrogation/crossexamination.
• Putthe personat ease - assure themthat the missionis "fact"findingtopreventarecurrence.
• Avoidintimidatingvoice andbodylanguage.
• Getthe individual'sversion
 Avoidinterrupting
 Don't put wordsintheirmouth
 Don't make judgmental statementslike "thatwas sure a dumbthingto do."
 Don't ask leadingquestionsandavoidyes-noquestions.
• Give the witnesssome feedback.Repeatinformationto ensure understandingandprovide a
chance for correction. Thiscreates"active"listeningonthe partof bothparties.
• Use visual aids(sketches,digital photos).
• End ona positive note.Thankthemfortheirtime and effort.Asktheirideas onhow thissituation
couldbe preventedinthe future.Keepthe line open.
INFORMATION GATHERINGFROMOTHER SOURCES:-
Dependingon the situation,othersourcesof informationmaybe helpful,suchas:
- TrainingRecords
- Maintenance records(repairandPM)
- Safetyinspectionreports
- JHA,JSA , JSP andMOC documents
- Changesinproductionschedule,materials,toolsandequipment

3. - Special testingsuchasMaterial Failure Analysis
- Drawingsandphotos*
Note:If you use photography(stillorvideo) be sure tophotographfromall anglesandprovide scale
reference.
EVALUATION OFDATA ANDIDENTIFICATION OFCAUSES(ROOTCAUSE ANALYSIS) :-
- Immediate causes(symptoms)
- Basiccauses(the why)
"CARELESSNESS"ISNOT AN ACCEPTABLEREASON FOR "WHY" AN ACCIDENTHAPPENED.
WE SHOULD ASK"WHY" WASTHE PERSON "CARELESS".
SUMMARY: Effective incidentinvestigations:-
Determine what“really”happenedratherthantry andprove what we “think”happened.
Provide anassessmentof the losspotential associatedwiththe event(Risk).
Provide the informationnecessarytostrengthenourproactive preventiveprogramcontrols(PRE-
CONTACTSTAGE) andassistin improvingourlossminimization controls(“Damage Control”–
CONTACTSTAGE).
Define incidenttrends
Demonstrate concernandimprove perception