Investigation Series 2 - Gathering and Analysing the Evidence
In my last article, I asked you how prepared are your workforce to manage a serious incident? I hope you found the article of interest and were able to take some helpful hints and tips from it! As a result, a number of you have contacted me and asked for our help and support to review and improve your own investigation procedures and processes. Others have asked us to provide a more detailed overview of our own investigation model which has been developed because, although no two clients are exactly the same, we have been involved enough investigations to determine that there are some common error traps which exist in the majority of corporate investigation processes.
Therefore, what was intended to be just two very high-level overview articles will now be a series of more detailed pieces intended to step you through our own "Paradigm Investigation Model". Even if you only focus in on one or two specific areas for improvement you will be amazed at how the quality of your investigations can increase significantly.
So, having made sure you have got your investigation off to a flying start in my first article, let's now take a deeper look at the gathering, capturing, recording and analysis of evidence.
As we have already discovered it is often the case that following a serious event the organisation is in a state of shock, temporary leadership paralysis and a feeling of failure mixed with sadness and sometimes utter despair.
This environment can put even the most competent investigation teams under significant pressure. They have a job to do but they are acutely aware of the increased emotions of the people they most urgently need to speak to and engage with.
Despite this, it is vital that evidence is gathered as soon after the event as is practicably possible; of course, if the event has been significant enough to warrant police or regulator intervention then the incident scene itself may be classed as a crime scene and this will, of course, mean that it is out of bounds to our own investigators until it is released.
Just remember to check in with your investigation team; it can be mentally, emotionally and physically challenging to be part of a team investigating a serious incident. Think about this when selecting your team and make sure you have things in place to help them cope such as access to counsellors, support groups and workplace mental health champions.
What is Evidence?
One dictionary definition of evidence is: The available body of facts or information indicating whether a belief or proposition is true or valid.
Certainly, we will be looking for a whole range of tangible items such as broken or damaged fixed plant, equipment and/or infrastructure, damage to the local environment such as fire or flood damage, tools and equipment being used in the activity such as ladders or screwdrivers, chemicals, substances, barriers, fall protection, warning signs, PAT test stickers, etc. We might need to quarantine large pieces of equipment or plant for inspection by experts such as scaffolds, forklift trucks, production lines, etc. Every reasonable effort should be made to ensure that the investigation team have undisturbed access to this equipment and that it is securely stored until they agree to release it.
We will begin to collate any documentation relevant to the task or activity, for example, procedures, safety plans, work instructions, the point of work risk assessments, permits, risk assessments and method statements. We should request training records, competency assessments or trade test results not just of those immediately involved in the incident but of those involved in the activity, anyone who set them to work, issued a permit or visited the job before the incident occurred.
Scene of Incident
Make sure we record information about the scene of the incident. Look for clues, what is out of place? Is anything missing? Is anything here that shouldn't be? I recently visited the scene of an incident where someone had suffered crush injuries which were inconsistent with the event being described. A large, heavy piece of replacement equipment was being manoeuvred into position by several people when the injury occurred. The incident itself was fairly self-explanatory based on the statements given something felt 'off'. The investigation really opened up when I asked how the piece of equipment had been transported onto the 1st-floor platform 60ft off the ground with no hoist, crane or other lifting devices in sight! It transpired that the load had been manhandled up the staircase by the team and had slipped, crushing the injured person against the handrail which then explained his rather unusual injuries! Sometimes you can learn more about an event and the safety standards at a workplace by thinking outside of the box but more of that later.
Don't forget to take measurements, identify the weights of things if relevant, pick up small items nearby that might form evidence, take photographs, draw sketches, establish access and egress points and routes, details of other work parties and activities in the vicinity, look at other permits issued on the same equipment and the associated works.
We talked about how to protect the witnesses in my first article of this series and we also know that witness interviews should be done as soon as physically possible after the incident. In my next article we'll talk about how to conduct witness interviews in detail but in this article, we are going to think about WHO we need to interview and why.
It is very easy to decide that we need to interview any people directly involved in the event. We also probably know that we need to interview any witnesses in the vicinity but here is a list of other people you should consider as part of your witness interview programme:
* Permit Issuer
* Line Manager
* Individual who set the working party to work
* Author of Method Statement and Risk Assessment
* Department Head
* Specialist Trainers
* Next of Kin
* Handover team/s
* Control room personnel
* Production Line Managers
* Equipment maintainers
* Equipment manufacturers and designers
* Previous similar incident investigators
* Retired or ex-employees
* Occupational Health
The list is longer than you might at first think but each of these individuals has a story to tell and we'll discover how to open that story up next time.
Procrastination point (or the Cape of No Hope as we call it) is normally the place where a client has got to in an investigation when they reach out to us.
We often arrive to find a disengaged, tired out investigation team who have typically spent between a week and ten days busily collecting evidence, interviewing witnesses and fending off senior management who need answers. They are now sitting looking at a lot of conflicting, confusing information, evidence, witness testimony, technical data, test results, etc., etc. but don't know how to move forward from here.
Many investigation teams are never taught the art of analysis!
Once the team reaches Procrastination Point, and in our experience more than 95% of teams do, we advise our clients to have a sponsoring manager intervention to support the team, help them to re-energise and to ensure that they have everything they need to continue.
The need to start to make sense of (or analyse) the information and to start making some decisions; many organisations do not have clear protocols for delegated decision making which can create a stumbling block for an investigation team who needs to make decisions about causal factors and corrective actions!
To analyse investigation evidence, we use a technique called 'Event Causal Factor Analysis', which involves working through each piece of evidence in a methodical way, inspecting, reading, challenging and comparing it to other evidence, highlighting inconsistencies. Where inconsistencies are identified we go back over our notes and findings; if necessary re-interviewing specific witnesses to validate the information as far as we can. We then use our validated facts to conduct our primary sequence timeline. We overlay this with our contextual information and secondary events and conditions to provide a visual representation on the whole event from start to finish.
The next step is to use the chart to identify critical steps (points of no return), causal factors and root causes; of course we are also interested in understanding the presence of human error in events and whether people were set up to fail or succeed by the organisation but not all of our clients want to go to this level of detail at first.
We often use the ECFA to talk senior managers through the investigation timeline, it is a powerful tool, not only in demonstrating how the event unfolded but also in showing them that the investigation has been in depth and professionally conducted.
We often advise investigation teams not to decide on or issue corrective actions (with the obvious exception of immediate safeguards and extent of condition risk management which will be covered in a separate article) until the management have been talked through the ECFA because using this method often makes corrective actions so much easier to agree and capture with top-level buy-in and sponsorship.
We would love to hear from you if you have found a successful solution to investigating incidents in your organisation and of course we would love to support you if you haven't!
More insights coming soon.