Incident
Investigation -- Tips, Techniques & Trivia
The
media recently highlighted some good investigation work by an
Edson, Alberta RCMP member. A single vehicle rollover had resulted
in the death of one person as the result of being ejected from
the vehicle, and the victim was at first felt to be the only
occupant. However, through interviews, DNA evidence and the
analysis of the vehicle's black box (Event Data Recorder) the
police have determined a second person was driving the vehicle
and had fled the scene. The black box indicated the driver's
seat belt was being used at the time of the collision.
A good example of an investigator using intuition, experience
and technology. The same opportunities are available to us in
workplace investigations.
Jeff
Investigation
Payback
Is this incident worthwhile investigating?
To answer
this question consider:
- Are the consequences serious enough to be worth
the effort of the investigation investment?
- What will be the return be on my investment
in investigation time and effort?
- Is this a failure that could lead to more
serious failures, or are the consequence of this failure minor
at best?
- Is this a repeat failure that happens so frequently
that stopping multiple repeat failures is worth the investigative
effort?
- Is this some management, regulatory, or public
relations "hot button" that may be worth investigating
for political reasons?
- If the incident is not worth investigating,
you can record the event in a database so that you can trend
the failure type and location. Future data may show an increasing
trend of failures or an unacceptable rate of repeat failures.
Some may see this lack of small investigations
as a problem. After all, if investigating big problems and performing
root cause analysis is a good thing, why not do more for smaller
and smaller problems?
First, most small investigations are done halfheartedly.
That makes for poor investigations. And since the problem is small,
they don't get a peer review and get little management review.
Because of a lack of effort, the real causes are not discovered
and the corrective actions are a waste of time and effort.
Second, no matter what your philosophy is about
small investigations, eventually everyone must agree that everything
can't be investigated. So management needs to provide direction
and guidance for the appropriate cut off for root cause analysis.
So consider developing clear guidance.
SOURCE: TapRoot Newsletter December 07
Many organizations treat all their incidents the
same from an investigation perspective. That is, a one size fits
all approach. This may be a waste of valuable resources, primarily
your time as the investigator. Use the time saved from not doing
trivial investigations to do a much better job on the critical
ones.
Jeff
Aftermath
of a Workplace Accident
Fort
McMurray, AB January 24, 2008
This session is sponsored by the McLennan Ross
law firm and I have had the privilege of participating in past
seminars and will be involved again with the Fort McMurray session.
-- Jeff
This seminar was presented in Edmonton and Banff
during April and due to popular demand, a session in Fort McMurray
is being offered. This extraordinary full-day seminar features
a courtroom demonstration by a real judge, prosecutor and defence
lawyer, demonstrating the inner workings of an OHS trial.
Register
for this session.
Investigation
Axioms
AXIOM:
an established or widely accepted principle
Abstractions cover up poor investigations.
S.I. Hayakawa
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