Incident Investigation: What Key Points Should We Discuss and Define Together?

Dear All,

Can we have a discussion on Incident Investigation? Can anyone come up with a definition for this? What points must we cover under Incident Investigation?

Hello Dipil,

Attached is a presentation that outlines the definition and aspects of the investigation process.

Regards

Really, a very useful information is contained in this PowerPoint presentation. It will help us greatly in investigating and analyzing accidents, and we can also draw conclusions to prevent the same.

Thank you once again.

Arindam Ray
Asst. Manager P&A
GTZ (India) Pvt. Ltd.

Hi Ronald Mackenzie, the presentation is very good... No doubt...

But I slightly disagree with a few points:

Points of Disagreement

Your presentation says that we should include the names of the following in the report:

1. Injured worker(s) or worker(s) involved name(s)
2. Name of Supervisor and Department

However, as far as I am concerned, we can provide the names of the persons involved in the incident in the preliminary report only. There is no need for any personnel names in the detailed Incident Investigation Report. By giving names, this may divert the entire purpose of an investigation. Naming individuals could lead to direct blame on one person, which must not be the purpose of an investigation.

The focus should be on identifying the key factors that lead to an incident and eliminating those to avoid recurrence. Blaming anyone must not be the purpose.

Missing Elements in the Presentation

A lot of things are missing in the presentation, such as who must investigate, how to investigate, and which tools to use for investigation, etc. However, overall, the presentation gives a brief idea about the investigation.

With regards,

Dipil Kumar V

Definition of Investigation

An investigation is a methodical, systematic, unemotional undertaking to collect and interpret information about an event to establish the extent of an injury or loss, why it happened, and to analyze the process involved to minimize the risk or prevent a recurrence. The investigation will normally result in the preparation of a logical, sequential report of the events with recommended preventive strategies.

Regards,
Dipil Kumar V

Re: Incident Investigation

Dear All, it was an informative presentation on Incident Investigation. I conduct Accident/Investigation management training in Malaysia. The key point is the analysis of the findings to determine the root cause (normally a failure in management systems) and come up with solutions to prevent their recurrence. It is also important to ensure weaknesses in the system have been rectified so that similar or other incidents do not occur again.

I am attaching a presentation that I use for my training. I hope it will be helpful.

Thank you.

Dear all,

Very rarely does one find such a beautiful presentation and a relevant discussion with an excellent PowerPoint. My compliments to everyone for bringing an interesting topic to the forum.

Incident Investigation in Industrial Security

I would like to share a perspective on the subject of incident investigation. As an Industrial Security Consultant with ten years of experience in the field, we often encounter incidents related to theft, pilferage, missing movable assets, and information security breaches. These issues are part of HR management.

We conduct thorough investigations into each incident, regardless of the outcome, which can range from one day to one month depending on the nature of the incident. The process involves a detailed study of the people, profiles, and systems within the organization connected to the incident. This exercise serves as an eye-opener for the organization, helping to reduce risks in protecting human capital and preventing potential security threats that could lead to property loss or misappropriation of funds.

If there is interest on this platform, I can share more insights.

Thanks,
V. Rangarajan

Dear All,

Thanks for the active participation in the discussion. Let us now select a specific subject under Incident Investigation. We will change the same and delve deeper as and when time allows and if all are interested.

Best Proven Tool for Incident Investigation

As per your opinion, which is the best proven tool for Incident Investigation?

@ Gopinadhan Pillai...

The presentation is very good, a nice and knowledgeable one. Thanks for sharing.

@ V. Rangarajan...

We are here only because of the interest in discussion and thereby gaining knowledge. So, we request you to come up with your views and good postings.

With regards,
Dipil Kumar V

ACCIDENT INVESTIGATION

CHARLIE'S ACCIDENT

Charlie had an emotional argument with his wife and proceeded to the local bar where he consumed several drinks. He departed the bar in his car at high speed. Minutes later, he lost control on the highway and was fatally injured. We know what happened; we must now determine 'WHY' it happened.

The investigation team is comprised of six specialists, each of whom has a completely different perspective on the root safety deficiency.

1. Sociologist
2. Enforcement Officer from the Liquor Control Board
3. Pathologist
4. Highway Engineer
5. Automobile Engineer
6. Policeman

The sociologist identifies a breakdown in interpersonal communication within the marriage. An enforcement officer from the Liquor Control Board notes the illegal sale of alcoholic beverages by the bar on a "two for one" basis. The pathologist determines that Charlie's blood alcohol was in excess of the legal limit. The highway engineer finds inadequate road banking and protective barriers for the posted speed. An automotive engineer determines that Charlie's car had a loose front end and bald tires; the policeman determines that the automobile was traveling at excessive speed for the prevailing conditions.

Each of the deficiencies may result in a different definition of the underlying hazard.

Your final report with recommendations to avoid recurrence, please...

Regards,
Kesava Pillai

Dear All,

Key Aspects of Incident Investigation

Among the team selected for investigating any incident, at least one member should have knowledge of Root Cause Failure Analysis. Recommendations should include both corrective and preventive actions. Furthermore, the communication of the investigation findings, along with these recommendations, is a major part of the investigation process. Lastly, but most importantly, follow-up is a crucial part of the process.

With regards,

Dipil Kumar V

Dear all,

Please let us have a specific discussion: Which is the best proven tool for incident investigation? Or which tool are you using for incident investigation?

Hope to have a good debate on this topic.

With regards,
Dipil Kumar V

Dear all, from the perspective of security and risk reduction management, in my experience, I would like to share the following for the benefit of HR, Administration, and Security departments.

Usually, incidents of less significant nature do not occupy the attention of stakeholders unless these incidents occur with striking regularity.

Incidents Involving Any One or Some:

1. Loss of calculators, desktop holders, stationery, small cash, timepieces.
2. Breakage of table glass without the knowledge of the occupant in a room in their absence.
3. Regular misplacement or loss of drawer keys or cash keys.
4. Regular damage to the drawer or any of the important cabins in the office.
5. Missing furniture or light systems without proper authority.
6. Regular missing of lights in the lift of the office.
7. Unusual expense patterns on housekeeping materials.
8. Unusual maintenance expenditure in facilities management or the storeroom.
9. Sudden missing of the company's scrap materials.
10. Discovery of unused or new company property in the scrap disposal.
11. Inordinate delay in receipt of returnable company equipment, items purchased originally by the department.
12. Non-maintenance of receipt and balance of returnable company materials sent for a specific purpose.
13. Regular opening of stores/materials department outside regular working hours.

A well-run organization may have a well-designed manual for each of the above areas. It is seldom followed because of a lack of supervision, control, and involvement, mainly due to a lack of integrity in the system itself. Because the system drives people and people drive the system.

All these are considered system lapses or administrative errors that do not get the due attention if there are no proper SOPs and NCRs. Usually, these events do not get escalated to the next level by the concerned for rectification.

Therefore, SOP and NCR are the first steps to prevent the occurrence of these incidents. Discussion may continue. We will discuss soon in the coming days.

Thanks and regards,

V. Rangarajan.

Dear Mr. V. Rangarajan,

Nice to share your rich experience with us. First of all, sorry for the late comment.

Case Study: Theft of a Laptop

Let us consider a case - the theft of a laptop from the office within your area of monitoring. How will you proceed further? What techniques/tools will you use to investigate this case?

With regards,
Dipil Kumar V

Dear all,

Theft of Property: Movable and Immovable

Theft of property comes in two forms: movable and immovable. These properties must be handled following proper procedures and standard operating procedures (SOP). Documentation should strictly adhere to the prescribed format.

Security Procedures and Policy Alignment

Procedures and the implementation of security rules and regulations must align with the policy design. Security, being a sensitive and critical department, is directly linked to Top Management. Any incidents related to theft, pilferage, or sabotage should be promptly and thoroughly investigated.

Challenges in Conducting Investigations

Conducting a detailed inquiry lacks a scientific tool or prescribed format in HR or Criminology to extract information from individuals. The offense originates in the mind and is executed by the human body. There are no scientifically established rules to identify criminal intent, as there are no qualifying criteria based on gender, race, religion, or academic qualifications.

Investigating Laptop Theft: Key Considerations

Investigating a laptop computer follows a detailed method, varying from one organization to another. Some key questions and issues include:

• How many laptops are in use?
• Who is authorized to use them within the office premises or related work areas?
• Who has access regardless of possession?
• Policy compliance in case of loss or damage by users or non-users.
• Access limitations.
• Security procedures during usage, including entries, names, signatures, dates, times, and pass issuances.
• SOP for usage during domestic and overseas travel.
• Storage devices utilized by users.
• Vendor access during maintenance and repairs.
• Responsibility and accountability, with written agreements in case of loss or mishandling during transit.

Experience with Laptop Misuse and Theft

In my experience, I have encountered instances of misuse, damage, and theft of laptops in leading organizations. Despite clearly defined rules, organizations often refrain from penalizing offenders. Typically, individuals involved in laptop theft are educated, tech-savvy, intelligent, and knowledgeable about security protocols, often using or facilitating the use of stolen gadgets in some way.

Companies frequently opt to report incidents to the police, anticipating the outcome and repercussions, leading to cases being closed and forgotten, with insurance claims as the resolution.

My approach to identifying suspects or offenders differs significantly in my experience.

Best regards,

V. Rangarajan.

Dear Mr. Kesa Pillai,

It is not very often that we discuss something useful. Unlike other topics such as training, business opportunities, and immature questions and thoughts, your inputs are valuable and stimulate our minds for long-term processing in our daily lives.

Thanks and regards,

V. Rangarajan.

Dear Mr. Rangarajan,

Thank you, sir. I am glad that a few individuals like you, who have achieved high positions in the profession, are watching it. I will strive to be a part of this endeavor to impart what I have gained while in service and protect it from simply rusting.

Regards,
Kesava Pillai.

Hi Dipil,

Please find the attached file of 'Investigating Chemical Process Incidents'. It may be useful for you.

I have information about accident investigation that I found through a web search. I hope it helps.

Regards,
Samy

HSE
Qaroun Petroleum Co.
Egypt
[Phone Number Removed For Privacy Reasons]

I had prepared a procedure on Reporting & Investigation for an upstream Oil & Gas company in Sudan a few years ago. It may be useful to some of the members.

Regards.

Dear Ronald & Gopinadhan, First of all, thanks for sharing the information. Accident investigation is a fact-finding report and not a fault-finding report. If we concentrate on the fault or putting blame, then the very purpose of the investigation fails. The accident investigation helps in finding the root cause and preventing such types of repetitive accidents in the nearby future. For this, corrective steps are needed to be strictly complied with.

Regards,
Deepak B Dorik
Sr. Manager-EHS
JBF Industries Limited

Basic Accident Investigation Procedures

Basic accident investigation procedures include interviews, plans, photographs, relevant records, and checklists. The process involves identifying immediate causes (unsafe acts and conditions) as well as root or underlying causes (management system failures), and subsequently determining remedial actions.

Ideal vs. Reality in Accident Investigations

In an ideal scenario, an investigation should be carried out by an expert in accident causation, well-versed in investigative techniques, and possessing comprehensive knowledge of the work processes, procedures, individuals, and industrial relations environment specific to the situation. However, in reality, investigations are typically conducted by a manager from within the organization, with support from a member of the safety team.

Importance of Impartiality

It is crucial that the individual conducting the investigation remains impartial. Initiating the investigation with the intention of assigning blame invariably leads to failure. It is essential to recognize that even in seemingly straightforward accidents, there are typically multiple contributing factors.

Key Aspects to Consider During Investigation

During the investigation, particular attention should be given to various aspects, even if they are not immediately evident:

- Materials used by the employee
- Environment in which the individual was working
- Personnel assigned to the task
- Management's demonstrated commitment to safety
- Previous audits
- Physical evidence, and so forth

Thank you,

Sam