ICAM Investigation In Times Of A Pandemic
Investigating safety incidents is rarely easy and doing so remotely can be even harder. But in the new normal of today where people and organisations are physically distancing, so must investigators. So, what does an ICAM investigation look like in the time of COVID-19?
I recently received a call from a client regarding a fatality that had occurred at one of their mine sites. The incident scene had been secured, family members, local authorities and the corporate office had been notified and the Corporate Crisis Plan had been initiated. A basic statement of events had been received. This information was used to ensure necessary information was provided for initial notification to relevant persons and to meet regulatory requirements. Trauma counselling was underway. An ICAM team had been formed at the site and the decision made to have an external facilitator lead the team through the investigation.
I received the call to assist later that evening. Usually, I would be making immediate arrangements to be on the next flight out, but COVID-19 put a stop to that. This investigation would need to be facilitated remotely, from my home office in Toronto. This was the first time I had ever participated in a remote investigation and I was feeling apprehensive - all I could think about was the potential challenges that a remote investigation presented. The two biggest concerns were the 7-hour time difference and the inability to complete in person interviews. Other more minor issues included the inability to familiarise myself with the incident scene, reliance on the site team for all of the data collection, assessing witness credibility, internet connectivity in a remote location, document sharing, and lastly, ensuring confidentiality.
At the onset I had thought the 7-hour time difference would be the biggest challenge that we would face, but the time difference worked in our favour. I have two young children, one of which is currently at home permanently, which makes meetings and uninterrupted work something of a distant memory. The best time to work is when they are sleeping and so I arranged to meet with the team at 3am EST. We would work through until till 7am, giving us 4 uninterrupted hours every morning to complete key interviews, and to have a catch-up to review the previous days data that had been collected (I am certainly not suggesting that these hours are necessary, and would work for everyone, but in this case it did). The site team then continued with their normal workday and their investigation action items, and I would update PEEPOs, timelines, and ICAM charts with the data that we had. This served as a gap analysis by highlighting any information that was conflicting or missing that was still required. This turned out to be a very efficient process – for part of the day when the site team was sleeping, I was working, and vice-versa.
The second biggest challenge was the inability to complete in-person, face-to face interviews with those directly involved and witnesses at the scene. Interviews over the internet can be more challenging despite that technology has improved and there are more platforms available for use such as Zoom and MSTeams. I certainly had reservation about how successful these would be. If conducting remote interviews, the preference should be for video conferencing so that the interviewer can assess the interviewee’s body language and facial expressions as the interview progresses. It is also more personable. A number of witnesses we wanted to talk with where not at site during the week following the incident, which meant that the majority of people had no access to a computer. This is something that most of us probably don’t ever think about. Arrangements had to be made to use a company device on company property at a time that was suitable for all involved.
At the onset I was sure to inform the interviewee that the interview was not being recorded but that notes were being taken and an opportunity would be provided at the end of the interview to review for accuracy. I also had to remember to replace non-visual listening skills, like nodding of my head, leaning forward, maintaining eye contact, which I always rely heavily on during interviews with verbal cues such as “okay, thanks, yes, keep going”.
At times using video feed impacted the quality of the sound. It was crucial therefore that the interview took place in a quiet location and that the interviewer/ interviewee spoke slowly, clearly and made every effort to not interrupt. I often used paraphrasing (questioning technique where the interviewer considers what has been stated by the witness and restates it in his/ her own words) to ensure that I clearly heard and understood what the interviewee had stated. Using the mute button further assisted with reducing the amount of background noise and possible distractions.
Credibility of witnesses must always be considered and understandably many people raise the concern that it is difficult to assess if you are not in the same room as the witness. Yes, physical cues are important, but they are not the only means of assessing one’s credibility. Be sure to review consistency to statements provided by other key witnesses or third-party technical experts, review the physical evidence available from the incident scene, take note of the language someone uses and the plausibility of their statements.
Despite my initial reservations regarding interviewing online I was satisfied with the outcomes. Just as I would have when conducting an interview in person, being well prepared for the interview (using your PEEPO Mark#1 brainstorming as a guide), completing introductions and a thorough explanation of the purpose of the interview and the process ensured that we obtained sufficient detailed information and that the interviewing went smoothly.
Not being present at the site meant that there was no in-person face-to-face interaction with the ICAM team and I was obviously unable to walk the scene and get an idea of the incident location, environment, and conditions. As a result, there was reliance on the site team for the task of data collection. They were assigned with conducting non-critical interviews and to provide necessary information from the site which would have been different if I had been there in person. This turned out to be positive as it encouraged the site to be actively involved and engaged in the investigation process and the outcomes, possibly more than if I had been there in person doing the work with them. Of course, success will be dependent on the team’s exposure to ICAM and their willingness and ability to assist with the data collection. This particular site, and most of the investigation team members, had previously completed ICAM Training and it was evident in their understanding of the process and their willingness to roll up their sleeves and get involved.
Developing a detailed action plan with clear roles and responsibilities made certain there was meaningful participation and less wasted time and effort. At the end of each team catch-up meeting we updated the action plan for the following 24 hours to ensure there were clear expectations and deliverables for each person in the team – whether this was conducting a follow up interview, sourcing additional documents, review of current documentation, taking additional photographs and videos, obtaining technical records etc.
Remote investigations are reliant on quality internet, not just for witness interviewing, but for the valuable meetings and discussions between team members and the facilitator. As expected, we had some issues with the sound quality during some interviews and meetings and had a couple of calls unexpectedly drop. Although this was frustrating at times, it was manageable and did not impact the interviews and the overall investigation. At the start of our meetings and interviews I explained that it was possible that there would be connection issues and we decided together what the protocol would be if the internet dropped out at any point. This reduced people’s concerns and minimised confusion when it did happen, which was rare.
The remote investigation process must also ensure that there is a safe and secure means of collecting, sharing and storing documents related to the investigation. This should also be easily accessible to all team members. The IT team at the site set up a secure online portal where all data was available for anyone in the ICAM team to review at any time. As information became available from team members it was uploaded to this folder for review by the group.
Keeping information confidential when working from a home office can also present some challenges as it may not always be possible to have a secure location and maintain complete confidentiality. Investigators must make every effort to ensure that all sensitive information is kept out of public eye as much as possible. When completing interviews or meetings consider who is in your home and who hears your conversations.
Despite my initial reservations about remote investigations, I can honestly say that this turned out to be a positive experience. I was pleased with the outcome of the investigation, as was the client. Not only did they have a quality investigation that identified multiple contributing factors and made attainable and measurable recommendations for prevention of recurrence and reduction of risk, but they got all this at a significantly reduced cost. Investigating remotely meant that there were no costs incurred from travel and accommodation, the investigation started sooner after the incident as no time was taken for travel (the investigation referred to here would have required 4 days of travel), and the site team was more engaged and involved in the process.
Face-to-face investigations will always have their place in industry, and I suspect most organisations will revert to this approach at some point in the future. However, in my recent experience, a lot of the challenges are perceived and are easily overcome, resulting in an equally thorough investigation.
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- Mary-Jane Vince (Investigator/Trainer)
Mary-Jane has 12 years’ experience in the mining industry in Africa, North and South America developing best practice EHS management systems built across entire life of mine processes, from exploration, permitting, greenfield/brownfield construction, start up and commissioning, operations and closure.
The combination of technical skills and knowledge supported by practical industry experience with people of different cultural backgrounds has given Mary-Jane a high level of communication, understanding and adaptability to provide effective health and safety advisory and training services.
Her work has brought her into many unique and sensitive operating environments and as a result she is comfortable in multi-cultural stakeholder engagement, working with organisations, local communities and government to find mutually beneficial solutions to challenges in mine operations, expansion, rehabilitation and closure.
Mary-Jane joined the Safety Wise team in 2012 working in North America and Botswana, before recently relocating to Canada providing ICAM training, investigation and consulting services for clients in multiple industries.