The document outlines the steps and techniques for effectively investigating incidents. Some key points include: - Incident investigations are conducted to prevent similar future losses by learning from past experiences. - The primary investigator is usually someone directly involved who has knowledge of the people and conditions and can take corrective action. Managers may lead investigations of major losses or high potential incidents. - The investigation process involves an initial response, gathering information through interviews and other sources, analyzing the data to determine causes, taking or recommending actions, and writing a report with follow up. - Gathering factual information is important to understand what really occurred rather than making assumptions. Interviews should be conducted separately and in a non-accusatory manner

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