Incident Investigation Process & Methodologies

Incidents keep occurring at the worksite and it is necessary to control them on a long-term basis to ensure the safety and security of the workers, public, equipment, environment, and reduce the damage. An investigation is launched to check the root causes of the accident. As we know, there is more than 1 root cause behind an accident.

Steps To Take Following An Accident

If an accident takes place at the worksite, it is necessary to ensure the injured people are transferred to the hospital for medical assistance, the site is secured, if there is any fire it is controlled. Few actions are listed below to adopt in case of an accident before launching an investigation.

Emergency Response

The first essential action to take is to provide first aid to the injured people and if necessary, shift them to the hospital for proper medical treatment.

Initial Report

To ensure an effective investigation takes place, it is necessary to secure the site. A barricaded area is an example of it. No Entry tape can be used as well to alert others not to enter the area. If the debris has spread over an area, every debris landing site should be secured. Position markings should be done to keep a record of the landing sites. The main purpose of this action is to ensure that every piece of evidence is secure and safe.

Initial Reporting & Decision to Investigate the Incident

If there is any regulatory body, and by law, it is necessary to inform them, the concerned person must inform the regulatory body. Record of the information sharing must be maintained in the logbook. The consequences and level of reoccurrence will decide the level of incident investigation. The incident investigation level can be divided into 4 categories, each headed by a competent person.

a) Minimal Level Investigation

The supervisor looks into the circumstances for lesson learning and reports to senior management.

b) Low-Level Investigation

A short investigation is launched by the line managers to learn the immediate, underlying, and root causes of the accident so that its reoccurrence can be prevented.

c) Medium Level Investigation

Detailed investigation under the command of the line managers or supervisor is launched with the help of employees representatives, health and safety advisors to look into the matter and find out the causes.

d) High-Level Investigation

A team is formed to check the causes of the accident and ensure it doesn't occur again. The team can consist of the line managers, supervisors, safety managers, while directors will be the head of the investigation. 

The Investigation Process

Investigating an incident requires a predetermined investigation process should be in place, an experienced team, and resources to carry out an effective and comprehensive investigation. The process can be divided into the following parts.

STEP 1: Gathering the Relevant Information

The best time to start an effective accident investigation is as soon as possible after the event. The results will be more accurate if the window of time between accident and investigation is minimum. Facts will be clear, easy to understand, and more details will be acquired by those who were involved in the accident. Physical conditions are more likely to be closest to those immediately before the accident.

Following Equipment is required for the investigation process. It should be remembered that the equipment required can change according to the type and location of the accident;

Equipment	Usage
Camera	Digital camera is conducive to taking photographs rapidly and easily.
Lights	Portable lights maybe necessary if electricity is not available.
Sketch Accessories	Sketch pad, pencil, measuring equipment is required to make notes.
Recordkeeping	Recording device, notebook, video camera, etc.
Sample Collection	Jars, boxes, sealed polythene envelops are used for this purpose. The piece of evidence is secured for analysis.
Gas/Vapor Detector	Any area of accident site where dangerous/ flammable vapors, gases are likely to exist, gas detectors are used for detection before entry.

a) Inspection of Accident Site

The first priority should be to transport the injured and dead people to the hospital for medical treatment. As per law sometimes, the local regulator body must be informed. If the accident is serious, the site should be made safe and secure. Investigators should be present at the site when cleaning operation is going on so that no clue is lost.

b) Interviewing Witnesses

Interviewing will involve the people who were at the site. If they are asked questions e.g., what has been done or what is not done, they will get upset. The objective of interviewing the witnesses should be made clear to everyone that the main intent of the interview is to find the causes to prevent the reoccurrence instead of apportioning the blame or criticizing someone.

Types of Witnesses

Witness are divided into 3 broad categories;

The victim is known as Primary Witness as he/she is directly involved and knows exactly what happened, sequence of events that lead to the accident. He/she should be able to give full details of his/her actions.

The eyewitness (extremely rare in reality) is known as the Secondary Witness as they see the accident happening. The problem here is that not many people don't see the accident happening. They start watching once the accident has taken place.

Those people who give a variety of statements about people's actions, or any environmental circumstances around the accident scene are known as Tertiary Witness. 

c) How to Interview the Witness

Interviewing the witness is a skillful job. The first thing is to put the person at ease. The purpose of the interview should be explained to him/her. Tell him/her that the interview is done to find out the root cause of the accident instead of blaming someone. This thing will encourage him/her to play his/her role in finding the root cause of the accident. 

The interview location should be at the scene of the accident (if possible) because it is easy for those who are involved in the accident, to elaborate the chain of events, how the events triggered and got out of control, what were their actions to counter it but the accident occurred?

The questions asked should be in a sequence. The better technique is to adopt WH family method. for example,

1) What happened? What did you see? What time was it when the accident occurred?

2) Where were you at the time? Where was the victim shifted for first aid?

3) When did you realize something was wrong?

4) Who else was involved?

5) How were you involved in it? How did you respond to the emergency situation?

d) Attitude & Conclusion

The question "what happened" often generates an excellent response and the investigator must listen, without interruption to the witness's account of the accident. The investigator should look for the version of the witness, and should not disagree or make objections to any point about the witness's statement.

Once the witness has given his/her statement, the statement should be recorded and the investigator should repeat it to the witness to make sure he/she understands it. This practice also allows the witness to add any more detail to the statement if he/she has omitted it previously or forgot to mention it.

When the investigator and the witness are both satisfied that a true account has been given, the interview should end on a positive note by discussing the ideas the witness has regarding preventing a similar occurrence.

STEP 2: Analyzing The Information

Examination of the information acquired through visiting the area, recording the statement of the victims and witnesses and piecing them together to establish what actually happened and determining why it happened.

The acquired information is analyzed and the processed information in form of theory what actually happened leads to different areas of investigation. 

Following sequence can lead you to achieve this;

1. Assemble all of the data inform of interviews, and photos (evidences);
2. Extract the relevant information;
3. Identify the gaps;
4. Discover the underlying, immediate, and root cause;

The analysis of the information sometimes requires team-based approach, set of skills and experience together. For systematic consideration of all possible causes and consequences in complex system, formal investigation techniques can be employed to identify the causes and reasons behind an accident.

Note On Fish Bone/Cause & Effect Diagram

A Cause - and - Effect is an analysis tool, sometimes called a Fishbone diagram due to its structure. It was developed by Professor Ishikawa, who developed it in 1950s. It is often used in conjunction with brainstorming session. The below picture is an example of this technique;

STEP 3: Identify The Control Measures

Identify the control measures and select those which are most reliable. Their use can be justified through Cost-benefit Analysis. Consider also the wider implications of an event. It must be checked if the existing control measures were relevant to the job being performed, or with any change in the process the control measures were changed or not?

STEP 4: Plan And Implement

Decide what you have to do and what you have already done. Once you plan your strategy, implement it. It will require timescale, allocate specific responsibilities to the specific people, and check if the proposed actions have been adopted by all people. 

STEP 5: Review

Once your advised strategy has been implemented and being followed, verify the implementation of your strategy through audit/ performance evaluation.

If there is any requirement for change or improvement ensure it is reported to the higher management, and changes are made for safe and secure worksite.