10 Steps Towards Successful Accident and Incident Investigations

The detailed methodology that is used in any particular accident investigation depends on a variety of factors. Discussing these factors falls outside the scope of this article. The purpose of this article is to define and discuss the steps necessary for a successful accident and Incident investigation. Most successful investigations will include most of the following steps:

1. Define the Scope of the Investigation.

It is important that the width and depth of the required investigation is clearly understood by all the members of the investigation team. An easy way to ensure that this is achieved is to write down the scope of the investigation and get it approved by the authority who will receive the final investigation report.

2. Select the Investigation Team

The selection of the team should take cognizance of the fact that the investigators must be independent and informed. It is important to exclude any individual who may be implicated in the investigation. This is true despite the aim to steer clear from apportioning blame. Individuals finds in difficult to be objective if their careers or records are at stake. Once the team has been selected and appointed it is important to allocate specific tasks to each individual team member. This allocation of duties should be done with the scope of the investigation in mind and should be in writing.

3. Precondition the Investigation Team

The preconditioning of the investigation team is more than a training intervention. It includes a preliminary briefing to the investigating team. The briefing should include at lease the following elements:

• A detailed description of the accident that includes estimates of the consequences of the accident.
• A detailed revision of the standard operating procedures relevant to the activities associated with the tasks that led up to the incident or accident..
• A presentation of plans and maps of the area where the accident occurred as well as the general location orientation.
• A critical evaluation of the witnesses that has been placed on the provisional investigation witness list.
• A review of the events and circumstances that led up to the accident.
• Inspect the accident site

4. Conduct the In-Loco Inspection

An in-loco inspection of the accident site is a valuable tool to familiarize the investigation team with the conditions subsequent to the accident as well as the collecting of evidence. The rules for conducting an effective in-loco investigation include:

• Securing the area.
• Only enter the area if it is safe to do so for the investigation team
• During the in-loco inspection it is critical that the members do not disturb the scene unless a hazard exists that needs to be addressed on the spot..
• The deliverable from the in-loco inspection is the preparation of suitable and sufficient sketches and photographs of the area. It is often necessary to obtain professional plans and maps to be drawn up by a surveyor or drafts person who will label and reference each item and is exact position carefully
• The investigation team members should keep careful record of their observations and surveillance of the accident site.
• Interview Victims and Witnesses

5. Interview Witnesses

The interview is one of the primary sources of information. It is important that the team include interviews with persons who were present before the accident as well as those who arrived at the site shortly after the accident as well as eye witnesses. An accurate record of each interview should be kept by either making use of mechanical means of recording or taking down verbatim statements. The aim of these interviews is to determine:

• Any deviation from the standard occurring before the accident.
• Where the substandard condition first occurred.
• When it was first noticed.
• How it manifested.

6. Collect Physical Evidence

Another important source of information is physical evidence. Every accident site is a treasure chest of physical evidence to the practiced investigator. Collecting evidence at an accident site is an art and should only be done by investigators with special training. Often physical evidence is also available from sources other than the accident scene. This may include production data sheets, time sheets of employees and training records.

7. Analyze the data

The data collected in the previous steps should be carefully analyzed to reach objective conclusions. If, during the analysis of data it is discovered that more information id required any of the previous steps may be repeated if it is felt that it will contribute to filling in the gaps. The purpose of analyzing the data is to determine:

• Why the accident occurred.
• The likely sequence of events leading up to the accident and compare it with likely alternative sequences to come to a reasonable conclusion as to the most likely sequence.
• The probable causes of the accident based on the data available, including direct, indirect and basic causes

8. Prepare an Investigation report

The investigation team should prepare their findings in a formal report. The report should contain an executive summary, a summary of the facts and most likely sequence of events that lead up to the accident as well the probable causes of the accident and a final conclusion that includes potential issues for follow up

9. Conduct a post-investigation briefing.

It is good practice to conduct a post investigation briefing. During this briefing the investigation team should present the facts of their findings. They should refrain from speculating of making conclusions not based on fact.

10. Follow up and preventative action plans

The investigation report should be used to draw up a follow up and preventative action plan. The action plan should include the action step, the responsible person, any special resources needed, a timeline of completion and a formal approval of each action item by the person with the appropriate authority to enforce the completion of the action items

Conclusion

The purpose of an accident investigation should be kept in mind at all times. At any during the investigation it is discovered that the team is diverting from the scope of the investigation the lead investigator should make sure that the investigation gets back on track to avoid any delays in concluding the investigation.

An accident investigation that is done well has the potential to contribute significantly to the proactive prevention of future accidents, making the workplace a safer place to be for one and all.

© Carl Marx 2009