Incident investigations

Preventing workplace fatalities and injuries is every safety professional’s goal. However, when incidents occur, an investigation must take place.

That means securing the site, gathering evidence, speaking with witnesses and filing detailed reports that identify the root causes of the incident. No second can be wasted, especially in the early stages of the investigation, when memories are fresh and the scene has not been touched.

In other words, an incident investigator’s role is far greater than simply filling out forms.

“First off, you want to figure out what happened, how it happened and why it happened so you can try to prevent it from happening again,” said Steve Bump, a corporate industrial hygienist at Richland, WA-based safety services provider Dade Moeller.

“Second, you have to document the scene because there are going to be injury claims. There are almost always going to end up being some type of legal ramifications, so there is a lot of documentation involved.”

Calm under fire

Incident investigators usually need a number of tools to handle all of the technical aspects of their job. For instance, they need a camera, a voice recorder, measuring devices, a flashlight, sample containers, padlocks, barricade tape and investigation forms.

But another crucial element for an incident investigator is much more difficult to quantify. He or she must have an even-tempered personality and not be rattled by highly stressful situations.

University of Cincinnati Professor James T. O’Reilly served as a crisis manager at Procter & Gamble for 24 years. O’Reilly, who has authored 50 textbooks – many of which deal in part with incident investigations – said the right attitude is necessary for conducting a fair, thorough investigation.

“Being calm when everyone else around you is going crazy is an essential attribute of the job,” he said. “The fact that things have suddenly gone wrong and a fire or explosion or something like that occurred is quite unfortunate, of course, but it is important that you remain calm as the person who is going to interact with injured people and first responders.”

Bump agreed that an even-keeled approach is needed to achieve the best results.

“Keep the emotions out,” Bump said. “When you are at the accident scene, sometimes it may come off as a little cold, but you almost have to be like [Joe] Friday: ‘Just the facts.’”

How does one achieve calmness?

As with everything, experience helps. People with little or no experience might benefit from seeking out veteran incident investigators for advice about what to expect.

Preparation is important. O’Reilly recommends “tabletop” exercises in which several people – including a safety manager, site manager, fire chief and other emergency responders – join together for a model exercise focusing on how to respond if an incident takes place.

“Tabletop exercises are better than paper exercises,” O’Reilly said. “You say, ‘What happens if this occurs? What door, what gate are we going to use for the rescue equipment?’

“You might answer, ‘If we have a crisis here, we’d evacuate people through this gate, fire trucks are going to come this way, EMS is going to come this way.’ Tabletops make it more realistic.”

Look and listen

When an incident occurs, investigators need to act fast.

Once the scene is safe, it’s important to collect as much evidence as possible, as quickly as possible. Snapping photographs can help piece together evidence during later stages.

“More photographic intelligence makes it better to reconstruct a scene,” O’Reilly said. “It’s more likely than not that in the week or the two weeks afterwards, something is going to be moved, something else is going to be in a different position. ... If you’ve got a photo, you’ll have some basis to say, ‘OK, this is where the machine was at the time.’”

A calm demeanor also helps when interviewing witnesses, which is an essential part of an investigation.

The 14th edition of Administration & Programs, a textbook published by the National Safety Council, offers a five-step method for incident investigators to use when conducting witness interviews:

1. Describe the purpose of the interview as a fact-finding mission, not a fault-finding mission.
2. Invite the person to recount his or her version of the incident. Keep interruptions to a minimum.
3. Ask questions about any items that require clarification.
4. Repeat the facts back to the person to ensure you understand the sequence of events as described to you. This step helps prevent miscommunication at a later time.
5. Discuss ways to prevent the incident from reoccurring. Ask the person for ideas that could help eliminate or reduce the hazards involved in the incident. By asking for suggestions, you show sincerity and reinforce the notion of simply looking for facts, as opposed to assigning blame.

Bump said quickly preserving evidence and speaking with witnesses go hand in hand.

“You have to gather everything you can as quickly as possible before it gets messed up,” he said. “Because once you’ve lost control of the scene and lost the evidence, then you’re flying blind. And then people start talking and they start comparing notes, and stories start changing. ‘Well, maybe I didn’t see what I thought I saw.’ Stories start to converge, and maybe you start losing memories.”

Hold to principles

Incident investigators might be placed into difficult situations regarding personnel.

Be ready for those moments, O’Reilly said. Be prepared to stand your ground and do what is right.

“There will be incidents when you have to maintain your professionalism as an incident investigator,” he said. “The factory manager might say to the incident investigator, ‘Look, that’s a really valuable employee. I don’t want anybody to think that we’re blaming it on Joe. If you come to the conclusion that Joe did it, don’t put that in your report.’”

Yet facts are facts.

Incident investigators must remain objective and refuse to jump to conclusions. They must refuse to become caught up in workplace politics or worry about how they are going to protect the company and keep the incident from looking bad.

“If your professional conclusion is yes, a human error occurred, and yes, the human error occurred while this person was in charge of the machine, don’t accept the direction to bury that fault or to blame it on somebody else,” O’Reilly said.

The end result is a safer workplace.

“Obviously, something in the process happened where something went sideways,” Bump said. “So, what was it? Let’s figure that out. Let’s do a thorough root-cause and fix this process.”