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