Investigation Series 1 - Managing a serious incident
Unfortunately, it is often the case that the first time a new client reaches out to us is following a serious event; in a state of organisational shock, temporary leadership paralysis and a feeling of failure mixed with sadness and sometimes utter despair because nobody could ever have imagined that X could have happened.
This is certainly the case for a company that reached out to us recently, following an incident that nobody saw coming! Of course, the identity and the exact circumstances of this incident remain confidential, but this article is a reminder that when it comes to managing an incident, perfect planning prevents post-incident paralysis.
Obviously, we want to talk to you before you suffer an incident of any nature to help you prevent it occurring, but these are our recommendations for any organisation that finds itself in the aftermath of an incident:
After such an event your initial focus is to help the leadership team, your people and the friends, family and colleagues of any injured parties, to deal with the immediate aftermath - physically, mentally, emotionally and organisationally.
Next of Kin have to be informed, Regulators and other Authorities need to be notified, the Workforce need to be consoled and managed, perhaps reassured that they can continue to work safely, the 'scene' of any incident has to be managed, evidence has to be protected and collected, witnesses have to be interviewed and if you are a big name or the incident is serious enough you might have to deal with the press and media as well.
Then on top of all this your 'corporate' rules probably dictate that someone very senior must be given as much detail as possible about even the most insignificant incidents, within a specified time limit, we have even seen requirements for the CEO of a multinational to be informed of ANY lost time injury within an hour!
In our experience, what happens 'on the ground' in the first hour immediately following an incident often determines the effectiveness of the resulting investigation and its findings. It can change the story of how the event unfolded, what the actual circumstances immediately before or after the incident were and even determine an incorrect, unsubstantiated root cause. It's not called the Golden Hour in accident triage for nothing - learn to use this hour wisely and reap the benefits later. Here are some practical things to think about; the list is by no means definitive but we have focused on some of the more generic items you should aim to bolt down and your procedures and then practice, practice, practice!
Once the initial alarm has been raised the most appropriate and capable person at the scene should immediately become the 'Incident Controller' and take control, formally handing over the responsibility to other more senior, nominated or experienced colleagues as they arrive, with a de-brief on the situation so far. This means that the incident is being effectively 'managed' from the second it occurs or is identified, until the final corrective action or recommendation is closed out at some point in the distant future.
DEALING WITH CASUALTIES, DANGEROUS CONDITIONS AND UNSAFE ENVIRONMENTS
It is a legal requirement to have a suitable and sufficient number of First Aid trained people; if you don't have any then you need to put this near the top of your 'To Do' list! If you haven't audited recently to make sure you have the correct number deployed effectively around your business in terms of physical locations and shift-times then take an action to do this and repeat it on a regular basis. Staff changes, recruitment, promotions, redundancies and retirements catch us all out when it comes to basic training requirements such as this. Allow your first aiders and the emergency responders to deal with casualties without hindering them. We are not going to talk you through first aid specifics here!
PROTECT THE SCENE
All too often the workforce (and the leaders) is keen to get back to work as normal, particularly if the incident is not perceived as 'significant' and sometimes even if it is! This can be a huge mistake! Make sure the scene of any incident is made safe and locked down! Nothing apart from emergency personnel making safe or first aiders and their equipment should enter or exit the 'demarcated' scene of the incident. Barrier tape is a last resort if the area cannot be locked shut or physical barriers erected. This is to provide an opportunity to take measurements, photographs, etc. and of course to collect physical evidence. Whilst cleaning up the scene of an injury can feel like a respectful thing to do it can disturb or destroy vital evidence, so if possible, leave it until the Investigation Leader is happy for it to be handed back for operational use. If it isn't possible to physically lock down a scene at your premises in this way, you might need to consider having trained investigators on call 24/7 so that evidence can be gathered quickly following an event and the area returned to normal operations as soon as possible.
We have an Incident Grab Bag in our cars and we advise our clients to issue them to senior people who are likely to take control in the event of an incident occurring. The grab bag contains the following items and we highly recommend putting one together and keeping it to hand at all times:
* Full charged Digital camera (ATEX rated if necessary)
* Fully charged dictaphone (for recording your own thoughts and actions, not interviews unless your policy allows)
* Writing Pad and pencils/pens (waterproof)
* "Incident Manager" hi vis vest
* Tape measure
* Luggage tags (for labelling evidence)
* Polythene Bags (for collecting evidence)
* List of key contacts and phone numbers
* Witness statement template forms
* Flashlight (ATEX rated if necessary)
* Disposable Gloves
* Disposable Face Mask
* Other PPE as required
You might be able to think of other items specific to your environment and work conditions.
PROTECT THE WITNESSES
The sooner we can interview the physical witnesses and capture their statements the better, for them, for the injured person and of course for the investigation. Experienced and well-trained interviewers are an asset to any organisation and investigation, particularly if they are able to empathise with the witness; interviewing in this way can also act as a de-briefing tool, allowing the witness to share their story, talk through what happened from their perspective, capture their immediate thoughts and discuss how they are feeling can significantly reduce the likelihood of post-traumatic stress or mental ill health at a later date.
Move witnesses away from the scene, make them warm and comfortable, keep them hydrated and if possible don't let them leave site until they have been interviewed or at least been given a clean bill of health by an appropriately trained person. Remember shock can set in much later!
DRUG AND ALCOHOL SCREENING
'For cause' or 'Post incident' drug and alcohol screening is becoming the norm now for many companies. Do you have such a policy and do you or your workers know how to enact it following an event? Obviously if a person has been seriously injured and is under the care of a first aider or emergency responder you are unlikely to be able to screen them, but you should always make an effort to have screening for drugs and alcohol done in a timely manner, post-incident (preferably within 2-3 hours). If this is an area your workforce feel uncomfortable with then it is worth remembering that D&A testing dismisses any suspicion of abuse, beyond doubt! Promote this facet of your drug and alcohol policy as a beneficial tool for the worker, in the investigation armoury and it will become the norm; people will expect to be screened after an incident and in fact they will want to be screened to prove their normal functionality and judgement.
At this point it is unlikely that you will have identified a Lead Investigator and their team members (unless you have an on-call team) so it is important that, with so much to do, the tasks are delegated to make sure they get done and in the right order of priority. Look after what and who is in front of you and once the casualties are away and the area made safe don't be afraid to organise a 'stand down' to give yourself time to think and decide what your next steps will be. Things happen so fast and you need to take the time to get this right so stop, breathe and think!
APPLYING LEGAL PRIVILEGE
A sound understanding of key legal professional privilege issues provides a strategic advantage allowing you and your lawyer to refuse to disclose privileged documents and/or communications and/or to answer questions relating to the incident, in the context of an existing, pending or reasonably contemplated litigation and/or a regulatory investigation. If you are unaware of your rights under legal privilege you should discuss it with your company lawyer as soon as possible!
HANDOVER TO THE INVESTIGATION TEAM
Make sure a formal handover takes place, with all evidence both physical and electronic being explained and talked through. Too many times we see an investigation team being appointed days or even weeks after the event with no handover. This is like trying to find a needle in a haystack and is a complete waste of everyone's time and your money. Assign a Lead Investigator quickly or have a rota where someone is on call if need be. Get them to the scene of the incident quickly. If they have a day job, do not expect them to do a good quality investigation on top of their normal duties. Take them out of line or replace them with someone who has the time!
If you are a senior leader, CEO or Director you need to think about your internal reporting requirements and make sure that they do not impose unrealistic timelines and demands which detract from the management of the incident. Yes you need to know, yes you need to manage your stakeholders but what value are you able to add at 2 in the morning when the proverbial has hit the fan and your subordinates are busy dealing with all of the above? Are you going to get dressed, go down, interview witnesses, collect evidence or take photos? Are you going to take charge of the rest of the operation while your managers manage the incident? If not, stay in bed! Or better yet, get up and rewrite you internal reporting requirements immediately and make it clear that your first priority for your team is to deal with the incident and to keep you appraised of the situation as it develops. Do not ask what happened! Do not ask who caused it! Do not ask why it happened! Allow the investigation to uncover the facts as they emerge and don't put additional pressures on your team to give you the answers. It takes a team effort to create an incident and a bigger team effort to investigate it!
PRACTICE MAKES PERFECT
You MUST practice your incident response protocols! Hopefully you will never have to do any of this 'in anger' and if this is the case you deserve to celebrate your success! However, even if you 'simulate' an incident or 'reconstruct' a previous one this is a great way to exercise the muscles of your processes! Can you use a near hit report? If not then think of other ways perhaps using technology to continually refresh the skills of your workforce. This way if it happens for real you have the best possible chance of managing it professionally and without error.
PUT A TIME ON IT
Put a time limit on the investigation. Do not allow it to drag on unnecessarily but allow enough time to ensure that a quality job is done.
In my next article I will share some of the typical issues I come across with investigation processes and how you can overcome some of the common 'pitfalls' of root cause analysis and Corrective Action design.
More insights coming soon.