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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