A Structured Approach to Incident Investigation
We are often called to assist after a catastrophic accident, especially those involving a fire, explosion, structural collapse, toxic chemical release, pipeline failure, occupational fatality and/or major injury. These types of incidents trigger immediate cascading consequences including intense regulatory and media scrutiny, notifications to insurers, and the involvement of numerous affected stakeholders. All of this adds up to a major crisis that most organizations and legal counsellors struggle to contain without immediate outside assistance.
A structured approach to incident investigation helps ensure that all the causes are uncovered and addressed by appropriate actions. There are key steps we follow when we are involved in incident investigation.
Step 1 – Secure the Incident Site: In the event of an incident, the first critical step is to secure the site. This helps make the area safe and preserves the scene to assist in recovering and protecting evidence. The IFO Group has experts who can act as an incident commander to take ownership of site and implement plans on behalf of the client. The site often needs to be stabilized or demolished before it can be entered. It is common that the area is very unsafe and thorough planning goes into securing the site to protect people and assets.
Step 2 – Plan the Investigation: Based on initial findings from securing the site, the team needs to work to confirm what expertise will be required for the material investigation. What resources will be involved? How long do you anticipate the investigation will take? Does the incident complexity require a single investigator or a team?
Step 3 – Material Investigation: Once there is confirmation that the site is cleared without criminal activity and the right team is in place, the material investigation can begin. This step involves the collection of all relevant information related to the incident gathered from sources such as workers involved, witnesses, equipment on the scene and documents such as inspection reports and maintenance logs. In most cases, a catastrophic incident was not a single event but rather a chain of events. It is important to understand exactly what happened by digging into the finite details leading up to event. What were the operating conditions? Exact weather conditions? What process were workers performing at the time of the incident? It is vital to interview site personnel to gain observations, opinions, and insights into workplace norms, workplace culture and generally accepted behaviors.
Site investigation and evidence recovery takes a significant amount of time as evidence is commonly buried and/or damaged by fire. Quite often, a tiny fracture of something in pile of debris is very telling evidence.
Step 4 – Analyze Data to Determine Incident Root Cause: After data and evidence is collected, it must be analyzed to help find the root cause of the incident. The IFO Group has a climate-controlled inspection laboratory and workshop where we facilitate the inspection and documentation of collected evidence and artifacts from the incident. Process analysis and laboratory review are crucial and commonly involve modelling and simulation done through the input of variables – what happened before the accident, during, and after to help fully understand the sequence of events. It is important to remember that finding the immediate cause might fix the symptom of the specific incident but not the issue itself. Uncovering the systematic issues related to the incident rather than just the surface cause will successfully prevent reoccurrence.
Step 5 – Reporting & Implementation of Corrective Action Plan: Once the analysis is complete, the IFO Group creates structured reports and presents findings with recommended changes to client stakeholders. We then work with the client to implement recommendations. It is important to partner with the owner/operator and legal representation and perform services under privilege both effectively and timely.
We offer our clients the latest investigative techniques and technologies to maximize the collection of critically valuable knowledge that can be gained from a loss and provide the information necessary to fully protect an organization and its employees from future recurrences as well as prepare for any potential litigation. Get to know us before you need us. Please contact us so we may discuss how we may be your expert partner when your client calls you at 2 AM and tells you their whole world just came undone.
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