1. Incident Investigation New Mexico State Risk Management Loss Control Bureau and Law Offices of the Public Defender Loss Control Committee

2. Incident? Any unplanned event that results in personal injury, damage to property / equipment, or an event that has the potential to result in such consequences. Any unplanned event that results in personal injury, damage to property / equipment, or an event that has the potential to result in such consequences. Examples in the workplace that may require an incident investigation is any incident that results in a severe injury (falling, crushed under filing cabinet, roof falls in, workplace violence by co-worker or client, fire, flood etc…... Examples in the workplace that may require an incident investigation is any incident that results in a severe injury (falling, crushed under filing cabinet, roof falls in, workplace violence by co-worker or client, fire, flood etc…...

3. Parts of an investigation A. Why Investigate B. Who to Involve C. When to Investigate D. Where to Investigate E. What to Look For F. How to Proceed

4. Investigate by Asking? What happen? What happen? Who was involved? Who was involved? When did it happen? When did it happen? Why did it happened? Why did it happened? How did it happen? How did it happen? Responsibility for Investigation lies with management. Responsibility for Investigation lies with management.

5. Why Investigate Incidents? Incident Investigation is an Integral Part of a comprehensive safety, health, and loss prevention program. Incident Investigation is an Integral Part of a comprehensive safety, health, and loss prevention program. A. Determine Direct Cause. A. Determine Direct Cause. B. Prevent similar occurrences by implementing corrective actions. B. Prevent similar occurrences by implementing corrective actions. C.Document Facts. C.Document Facts. D. Provide Cost Data D. Provide Cost Data E.Reinforce Commitment to Safety E.Reinforce Commitment to Safety

6. Who Should Investigate Incidents? First-line Supervisor First-line Supervisor Employee Involved Employee Involved Safety, Heath and Loss Prevention Professional Safety, Heath and Loss Prevention Professional Others – Management / Insurance Others – Management / Insurance Note: Fairness and impartiality are essential.

7. When should Incidents be Investigated? All incidents deserve attention as soon as possible. (within 8 hours of the occurrence) All incidents deserve attention as soon as possible. (within 8 hours of the occurrence) Why? Why? 1. People forget important details quickly. 1. People forget important details quickly. 2. A short delay may permit evidence to be destroyed. 2. A short delay may permit evidence to be destroyed. Call 911 for automobile accidents and fires/floods. Call 911 for automobile accidents and fires/floods.

8. Where should incidents be investigated? At the site of the occurrence. At the site of the occurrence. Interviews may need to be held elsewhere if the site location is not safe or destroyed. Interviews may need to be held elsewhere if the site location is not safe or destroyed.

9. Identifying Causal Factors Fact –Finding (vs. fault-finding) is the core of a successful investigation. Fact –Finding (vs. fault-finding) is the core of a successful investigation. Usually a combination of elements contribute to incidents: Environment, Equipment, People, and Management. Usually a combination of elements contribute to incidents: Environment, Equipment, People, and Management.

10. Identifying Causal Factors Get specific incident data. Include the entire sequence of events leading to the resulting incident. Get specific incident data. Include the entire sequence of events leading to the resulting incident. 1. Employee – Time in current occupation, Frequency of Activity, and training. 1. Employee – Time in current occupation, Frequency of Activity, and training. 2. Narrative Description – What the person was doing, objects or substances involved, environmental conditions, acts of others. 2. Narrative Description – What the person was doing, objects or substances involved, environmental conditions, acts of others.

11. Identifying Causal Factors 3. Equipment – Type, brand, condition 3. Equipment – Type, brand, condition 4. Task – Specific or general, with others or alone, etc. 4. Task – Specific or general, with others or alone, etc. 5. Time Factors – Length of workday; Phase of workday. 5. Time Factors – Length of workday; Phase of workday.

12. Indentifying Causal Factors 7. Characteristics of an injury – Body part, severity, etc. 7. Characteristics of an injury – Body part, severity, etc. Analyze other similar occurrences or other incidents in general for clues and analyze to detect patterns. Analyze other similar occurrences or other incidents in general for clues and analyze to detect patterns. Indentify problems and solutions. Indentify problems and solutions.

13. Selecting Corrective Actions 1. Develop effective and cost-effective correction action plan to eliminate or control the hazard identified. 1. Develop effective and cost-effective correction action plan to eliminate or control the hazard identified. 2.Ask for suggestions from employees. Employees who are directly involved with a situation on a day-to-day basis often have different insights from an outside observer. 2.Ask for suggestions from employees. Employees who are directly involved with a situation on a day-to-day basis often have different insights from an outside observer.

14. How Should an Investigation Proceed? 10 critical steps in incident investigation. 10 critical steps in incident investigation. 1. Provide Emergency Response – Make sure a first- aid response is available. 1. Provide Emergency Response – Make sure a first- aid response is available. 2. Call 911 if appropriate. Secure the area – Isolate the incident scene (rope, tape, guard) Do whatever it takes to prevent another occurrence while preserving evidence. 3.Identity Potential Witnesses – Eye witness, ear witness or others who might have information. 3.Identity Potential Witnesses – Eye witness, ear witness or others who might have information.

15. How Should an Investigation Proceed? 4. Have investigation tools available – Camera, tape recorder, measuring devices, interview and investigation forms. 4. Have investigation tools available – Camera, tape recorder, measuring devices, interview and investigation forms. 5.Procure hard evidence and record data – Collect all evidence that can or may be used for your investigation. 5.Procure hard evidence and record data – Collect all evidence that can or may be used for your investigation. 6.Conduct Interviews – Use open-ended questions that cannot be answered with a just “yes” or “no” 6.Conduct Interviews – Use open-ended questions that cannot be answered with a just “yes” or “no”

16. How Should an Investigation Proceed? 7.Review data – Inspections reports, maintenance reports, prior incident reports and analysis. Are there patterns or trends? 7.Review data – Inspections reports, maintenance reports, prior incident reports and analysis. Are there patterns or trends? 8.Prepare an Investigation Report – Record key facts. 8.Prepare an Investigation Report – Record key facts. 9. Implement Corrective Action – This is critical to the prevention of future incidents that result in injuries, illnesses, and property damage. 9. Implement Corrective Action – This is critical to the prevention of future incidents that result in injuries, illnesses, and property damage.

17. How Should an Investigation Proceed? 10.Follow-up – 10.Follow-up – 1. Assure corrective actions that are decided upon are implemented by rules established for such action. 1. Assure corrective actions that are decided upon are implemented by rules established for such action. 2. Talk to people involved to assure necessary training was received and that the corrective actions work. 2. Talk to people involved to assure necessary training was received and that the corrective actions work.

18. Questions and / or Comments