FUNDAMENTAL 55: Incident Investigation

• Understanding the purpose and benefits of an incident investigation.
• Learning the common practices to follow and information to be gathered during an investigation.
• Realizing documenting and reporting responsibilities.
• Comprehending the importance of and common practices for determining root cause.
• Acknowledging the importance of implementing corrective actions.

Over 12 workers die everyday on the job; which adds up to over 4,500 a year.

An accident is defined as an undesired event which results in personal injury or property damage. On the other hand, ‘near misses’ describe events with no property damage and no personal injury, but where, given a slight change, damage and injury easily could have occurred.

When the safety professional is able to identify, analyze and fix the unsafe conditions behind a near miss, they are able to prevent incidents.

Absolutely nothing should be changed in the scene of an accident or incident, except when necessary to protect the workforce against existing hazards. The incident scene must be maintained as close as possible to its condition during the incident.

In an incident investigation, timing is everything. Over time, the ability to collect evidence and accurately determine what happened decreases. Therefore, investigations must start as soon as it is safe to.

Environmental conditions could change in the case that the investigation isn’t prompt. Water or chemicals can evaporate, instrument panel readings could be lost, and witnesses’ memories can get foggy, for example.

Below are six simple yet vital questions to ask when collecting data for an investigation:

– When was the incident? Discover the exact date and time because it may relate to shift-changes or work and break schedules.

– Where did the incident take place?

– What was the equipment, surrounding exposures, etc., that played a part in the incident?

– Who all was involved in the incident? Discover a list of witnesses.

– Why did the incident happen? List all factors that could have contributed to the incident.

– How did the incident occur? Describe how the incident occurred, including actions, sequences, procedures, etc.

Here are tools that help with investigations:

Chalk

Perfect for temporarily marking where events occurred, chalk is always helpful to mark locations and then take a picture as well, for reference.

Smartphone

Nowadays, smartphones are one of the most sophisticated investigative tools we possess, and also, workers often have one with them on most occasions. When you have your smartphone, use it to call for assistance, take pictures, record interviews, and reference emergency response protocol, etc. after an incident.

Camera

In the case that there are no smartphones around (perhaps because of sensitivity to the high-risk work environment), a camera is vital to any investigation. Some wide area shots of the incident in addition to numerous specific shots taken from multiple angles, document conditions close to the time of the incident and can reveal details otherwise overlooked or forgotten. Things to photograph include tire prints, broken glass, spills, frayed insulation, gauges, etc. Be sure to take as many photos as needed for complete documentation.

Video camera

A more detailed description of the incident can be provided by a video camera. If you are using a video camera, narrate the footage with a description of each item and area recorded. During interviews, video cameras help catch subtle facial expressions otherwise missed.

Flashlight

Additional light can be provided by a flashlight. Commonly, incidents happen during night time or in dimly lit surroundings. In these circumstances, a flashlight sheds additional light on clues.

Tape measure

Specific measurements give the needed details about the incident scene, equipment and materials, in addition to crucial, objective perspective to investigators. Saying “the scissor lift was about halfway extended” does not reveal nearly as much meaningful detail as “the top rail of the scissor lift was 11 feet, 3 inches above the ground at the time of the incident.”

Ruler

Rulers take accurate measurements which can be used in photos to show scale and perspective. One useful idea involves getting photos with a ruler next to each of Larry’s tools should be able to indicate if he was using the appropriate tools or not.

Clipboard/Incident Investigation Forms

Incident investigation forms lead the investigator through the process. In stressful situations, it’s helpful to have a form to walk us through step-by-step.