Incident Investigation

Incident Investigation • An incident is any unplanned event that results in personal injury or in property damage • The failure of people, equipment, supplies, or surroundings to behave or react as expected causes most incidents • Investigations determine how and why these failures occur • Prevention is critical: investigations are not to place blame

Fact Finding • Interview witnesses as soon as possible • Inspect the incident site before changes occur • Take photos and/or make sketches of the scene • Record pertinent data on maps • Get copies of all reports – Normal operating procedures – Flow diagrams – Maintenance charts – Reports of difficulties or abnormalities

Fact Finding (cont’d) • Keep complete and accurate notes in a bound notebook • Record pre incident conditions and post incident conditions • Document location of victims, witnesses, machinery, energy sources, hazardous materials

Interviews • Get preliminary statements as soon as possible from all witnesses • Locate position of each witness on a master chart (including direction of view) • Explain the purpose of investigation to each witness • Let each witness speak freely; take notes; use tape recorder only with permission

Interviews (cont’d) • Use sketches and diagrams to help witness • Emphasize areas of direct observation and label hearsay accordingly • Record the exact words used by the witness to describe each observation • Word each question carefully and be sure the witness understands

Interviews (cont’d) • Identify the name, address, occupation, years of experience, etc of each witness • Supply each witness with a copy of his/her statement (signed statements are desirable)

Problem Solving Techniques Change Analysis • Emphasizes change • Seeks deviations from norm • Finds unanticipated change • Analyzes change to determine cause

Elements of Incident Investigation • Define the problem (what happened?) • Establish the norm (what should have happened?) • Identify, locate, and describe the change (what? where? when? to what extent?) • Specify what was and what was not affected • Identify the distinctive features of the change • List the possible causes • Select the most likely causes

Report of Investigation An incident investigation is not complete until a report is prepared and submitted to proper authorities.

Components of Report • Background Information – Where and when incident occurred – Who and what were involved – Operating personnel and other witnesses • Account of the incident (what happened?) – Sequence of events – Extent of damage – Incident type – Agency or source of energy or hazardous material

Components of Report (cont’d) • Discussion to analyze how and why – Direct causes (energy sources, hazardous materials – Contributing causes (unsafe acts and conditions) – Underlying causes (management policies; personal or environmental factors)

Components of Report (cont’d) • Recommendations to prevent a recurrence—immediate and long-range – Direct causes – Contributing causes – Underlying causes