Incident Investigations- Appointing the Investigation Team
Whilst we hope that someone will not be injured or killed in a workplace incident, as safety professionals we need to be prepared for it. In this article we’ll explore the appointment of an investigation team to ensure that the investigation meets the incident objectives-
Establish the facts
Identify the contributing factors and latent hazards
Review the adequacy of existing controls and procedures
Report the findings
Recommend corrective actions which can reduce risk and prevent recurrence
Detect organisational factors that can be analysed to identify specific or recurring problems
Identify key learning's for distribution
The purpose of an investigation is not to apportion blame or liability.
Team members should not have supervisory control over each other or of the work site involved, nor should they have a potential for conflict of interest with the investigation process or findings. All members must be willing and able to devote the time necessary to the assignment and at least one member should have had training and experience in the ICAM incident analysis technique. Other members should have technical or operational experience relevant to the nature of the event.
The minimum composition should have:
Additional Subject Matter Experts (SME’s) can be bought in as required to provide specialist advice though they may not be required for the full duration of the investigation.
Consideration should also be given to include at least one member from either a separate department/business unit or a member from the workforce or union.
We don’t encourage the use of HSE team members to lead an investigation team as ultimately the responsibility for the investigation should lie with line management.
It is of utmost importance that the Terms of Reference for the scope of the investigation are established early and whilst this list is not comprehensive they should address:
Stakeholder requirements- internal, external, regulator, community, etc.
The requirements for legal privilege
The boundaries of the investigation
The jurisdiction of the Investigation Team
The authority of the Investigation Team
Expected date for completion of the report
It is important that specific guidance be taken from your organisations policies, however as a guide, we suggest the following:
Team Leader- The Team Leader’s role is to:
Direct the investigation.
Communicate and liaise with stakeholders and external parties as required.
Assign duties to the team.
Obtain the services of specialist advisers as required.
Schedule and co-ordinate investigation activities and resources.
Supervise preparation of the investigation report.
Brief management on the team’s findings.
The Team Leader should:
Be trained and competent in applying incident fact finding and analysis tools.
Have previous experience in comparable scale investigations.
Be skilled in effective management of a small investigation team.
Be able to act as liaison between senior management and the investigating team.
Investigation Team- Team members should not have supervisory control over each other or of the work site involved, nor should they have a potential for conflict of interest with the investigation outcome. All members must be willing and able to devote the time necessary to the assignment.
The team’s role is to:
Collect data, facts and evidence.
Establish the sequence of events leading up to the occurrence.
Analyse and integrate available information.
Develop findings and conclusions.
Determine the significance of findings.
Write the investigation report.
Present the report to management.
The Team should:
Have an ICAM Analyst who has been trained and experienced in incident analysis techniques and has facilitated at least two significant incident investigations.
Have collective managerial, technical and investigative skills.
Have members with open and logical minds who are thorough, able to maintain perspective and can overcome preconceptions or bias.
Have at least two of the team who have attended formal accident investigation training.
Include personnel with subject matter expertise in areas related to the accident.
Have access to specialist consultants, advisors or technical personnel as required.
Have access to legal advice.
The Team should not:
Have a supervisor and his or her subordinate serve on the same team.
Have members selected solely on availability.
Certain qualities are fundamental to an investigator. Since investigators are normally selected by position and knowledge needed in the particular investigation, the desired characteristics need to be developed by the investigator rather than the investigator selected by their present characteristics.
The following is based on the International Society of Air Safety Investigators (ISASI) Code of Ethics and Conduct (http://isasi.org/Documents/About/isasi_code.pdf)
Among the fundamental qualities are:
Integrity – being immune to influences of any kind, which may distort their objective use of information or bias the investigation. Fact finding requires truthful disclosures. Distorted findings lead to fault finding and blame fixing, and do not prevent other incidents.
Objectivity – to refrain from premature conclusions, to welcome evidence contrary to hypotheses and to consider alternative explanations for evidence.
Perseverance – to trace each symptom back to basic causes. Diligence to identify each deficiency and trace its roots back to the organisational factors within the system.
Curiosity – an insatiable desire to know more, to ask why? why? why? A team member who continually seeks deeper explanations of initial findings will be an effective investigator.
Observation – to see things as they are in detail rather than looking to see how they are in general. Looking with the mind as well as the eye detects the unusual, the out of place, and the source of contributing factors.
Imagination – to view things as they might and ought to be and mentally contrasting them with things as they are. Imaginative control of thought allows creative ideas to rise in response to the stimulus of a piece of evidence, and to subsequently reject those ideas and search for better alternatives.
Humility – to consider and admit that another can comprehend aspects of one’s own area of expertise and offer credible observations and ideas.
Intuition – to recognize a valid idea when it emerges after painstaking collection of data for analysis. In particular, the intuition to recognize the simple solution to a potentially complex problem.
Tact – and patience to overcome reticence to reveal self-critical information, and to use that information to enhance the investigation, not the investigator.
Technical skills – for equipment examination, photography, mapping, recording and writing are important, but secondary to the skills of perception described above.CONCLUSION
The appointment of the right team will ensure that the investigation meet the set objectives and scope.
Failing to resource the team properly will result in an investigation that doesn’t get to the root cause- remember the primary objectives are to prevent recurrence, reduce risk and advance health, safety and environment performance.
Interested in Knowing More?
Further information on Safety Wise’s Incident Cause Analysis (ICAM) Training is available from our website: http://www.safetywise.com/
Additional ICAM Related Services
Safety Wise also offers the following additional services for sites that adopt the ICAM investigation analysis method:
Quality review of incident investigations using ICAM
Trend analysis of organisational factors contributing to serious incidents
Participation in investigations as an external / independent party
ABOUT THE AUTHOR- Luke Dam (Chief Operations Officer)
Luke has worked in various industries over the years including pharmaceutical, retail, manufacturing, and transport including iconic brands like WesFarmers, Goodyear, CSL Limited, and Incitec Pivot Limited.
His work in OHS and learning and development has seen him deliver services to clients, both internal and external as well as managing service delivery teams around the world.
Luke holds a Graduate Certificate of Management (Learning) as well as a Diploma of Occupational Health and Safety, a Diploma of Training and Assessment Systems, a Certificate IV Workplace Training and Assessment, a Certificate III in Mine Emergency Response & Rescue and a Certificate II in Public Safety (SES Rescue).
Luke is extensively involved in a project to establish an association dedicated to confined space safety and to drive change in legislation to promote best-practice in this high-risk area. Luke is passionate about online OHS and incident investigation communities, moderating a number of large LinkedIn groups boasting over 11,000 members globally.