Major Accident Investigation – How To Plan One
What To Do Before Starting a Major Accident Investigation?
Having a major accident at your company is a nightmare. But it is even worse if you are assigned to lead a major accident investigation. What do you do???
This post explains:
- What is a major accident?
- When do you start planning?
- How do you handle the overlap between the incident response and the accident investigation?
- What do you do with regulatory/government investigators?
- What are the important standard factors in planning a major accident investigation?
- How do you develop restart criteria?
- How do you use a SnapCharT® to customize your plan?
- Where can you learn more?
What is a Major Accident?
Something with significant consequences to your company. It definitely includes any:
- Fatality (for employees or people living near the site)
- Significant Injuries (lost an arm, a leg, or sight in an eye)
- Significant Environmental Damage (extensive remediation required or adverse consequences to wildlife)
- Regulatory Response (threat to operating license or major fine)
- Adverse Press Coverage (front-page news and damage to corporate reputation)
- Significant Dollar Loss
- Significant Quality Issue (with adverse press or loss of customers)
These are accidents that should have been prevented by your proactive improvement efforts and investigations of precursor incidents. But, if you are investigating a major accident, your proactive efforts to prevent a major accident have failed.
When Do You Start a Major Accident Investigation Plan?
BEFORE the accident happens!
- Write an investigation policy. See TapRooT® Root Cause Analysis Implementation – Changing the Way Your Company Solves Problems for a sample version. You need this policy to:
• Standardize what gets investigated
• Require evidence preservation
• Specify the notification of company personnel and regulatory agencies
• Establish a restart policy for work or machinery
• Outline the investigation process
• Assign responsibilities
• Establish training requirements for investigation team leaders, investigation facilitators, investigation team members, and supervisors and employees.
• Establish special requirements for investigations that are conducted in preparation for legal action
• Specify the investigation review process
• Outline the corrective action implementation process, including corrective action tracking
• Define requirements for corrective action verification and validation
• Specify investigation report requirements
• Specify investigation report retention requirements
• Outline requirements for auditing and improving the investigation process
- Prepare for evidence preservation. Ensure that evidence is preserved by people in the field and first responders by having them use the SAy ESPN technique (described in the next section). Evidence preservation also needs to be considered for the investigation team (during the investigation) and after the investigation (retention of evidence for legal proceedings). Also, you should plan to preserve evidence while sharing it with legal authorities (Fire Marshall or police investigators) or governmental regulatory bodies (in the United States: CSB, DOT, EPA, FDA, MSHA, NTSB, NRC, OSHA, …).
- Develop investigation team requirements for certain classes of problems.
- Conduct training for investigation team leaders, investigation facilitators, investigation team members, managers, supervisors, and employees.
- Build an investigation kit (details in TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills).
- Establish contracts with expert consultants and laboratories for analysis of broken equipment and oil samples or for analysis of particularly complex human performance problems.
- Establish consulting contracts with expert root cause facilitators, equipment experts, and human performance investigation experts to assist with investigations that are beyond the skills of in-house investigators and might be needed on a quick response basis.
- Consult your corporate counsel about legal requirements and the discoverability of investigation materials. They can advise you on the laws as well as evidence preservation. Discuss the requirements of the particular jurisdiction concerning attorney-client privilege for investigations done in preparation for litigation.
With these details complete, you are better prepared to start a major accident investigation.
This can be tricky. Some government investigators may want to step in and take all the evidence. I’ve seen a regulator take all the physical evidence and tell the company:
“You can have it back when we are done”.
The physical evidence was crucial to the company’s investigation. They didn’t get it back for over a year.
It is best if you can work out some way to cooperate with the regulatory investigation and share information.
Talk to your attorneys and see what they recommend.
Overlap: Incident Response and Accident Investigation
You may have an overlap between the initial accident response (incident command) and the incident investigation.
Because of this overlap, the company Alcoa developed a simple initial response technique that could be used by supervisors responsible for the initial response to an accident. They named the technique “SAy ESPN.” Ron Pryor of Alcoa presented the technique at the 2007 TapRooT® Summit and a summary is provided here. SAy ESPN stands for:
S – Safely arrive at the scene.
A – Access and take control of the scene (evaluate for hazards, avoid creating additional injuries, establish incident command roles and responsibilities).
E – Emergency services – care for the injured; protect the environment.
S – Secure the scene.
P – Preserve evidence.
N – Notify appropriate company personnel and regulatory authorities.
Supervisory personnel at the scene after the accident should ensure that those who participated in the accident (and who were not seriously injured) and any emergency responders who observed important evidence fill out Initial Observation Forms before they leave.
The crossover between this initial response and the accident nvestigation usually occurs with the turnover of the secured scene and any preserved evidence to the investigation team.
Important Tactical Accident Investigation Plan Factors
Other important factors to include in your plan are:
- Safety of investigators and necessary personal protective equipment
- Initial videoing of scene
- Preventing contamination/damage to scene/parts/samples during evidence collection
- Evidence chain of custody (documented custodianship, including location and movement, of evidence from collection to destruction including use of evidence in court proceedings)
- Long-term evidence control/storage
You might think that a standard plan could be developed and used for any investigation. We have found that this isn’t possible, especially for major investigations (for example, Deepwater Horizon or Bhopal), the initial conditions change the immediate and follow-up actions that an investigation team performs.
However, certain factors are standard in developing a “tactical plan” for an investigation. Ron Pryor of Alcoa put these factors together into a Tactical Plan Outline that can be used by the investigation team leader in the planning phase of the investigation. The outline of the factors is shown below…
There is one more important question that management should ask before you start your accident investigation:
Should we allow the work, machinery,
process, unit, or plant to restart before
the investigation is finished?
Or another way to look at it:
What should we do to make sure that
this incident doesn’t repeat while we are
investigating the incident’s root causes?
Let’s look at a simple example that can demonstrate how complex these questions can get.
In this simple example, a construction worker fell to his death through an unguarded hole in the floor at a construction site. Once the emergency response was complete, the supervisor had workers erect a protective barrier around the hole so that no one else could accidentally fall through the hole.
Is that enough? Would you let work restart? Or do you need to:
- Know how the unprotected hole came to be there?
- Check the rest of the project for unprotected holes?
- Check the rest of the project for unprotected hazards?
- Train workers to report unprotected hazards and stop work until the hazard is fixed?
- Wait until the root cause analysis is complete and the interim compensatory actions have been implemented?
- Wait until the root cause analysis is complete and all corrective actions (fixes) have been implemented?
Even with this simple example, determining how “safe” the workplace needs to be post-accident is difficult. However, as a company, you should develop guidance that is based on your risk tolerance to guide management’s restart decisions after an accident.
One last item. In some industries, you may need regulatory approval to restart work after a fatality or other major accident.
Custom Accident Investigation Plan
Now you can start planning the details of this particular incident by using a SnapCharT®.
This planning SnapCharT® is used to:
- Develop an initial picture of what happened,
- Decide what information is readily available and what needs to be collected immediately,
- Establish a list of potential witnesses to interview,
- Highlight conflicts that exist in the preliminary information, and
- Plan the next steps in the investigation.
Here is an example…
On a planning SnapCharT®, recognizing what you do NOT know may be as important as what you do know. In this example, you do not know why they were replacing the detector. You don’t know if the lockout/tagout was properly performed. You don’t know if the proper PPE was being worn or if the pipefitters knew where the safety shower was. Thus, you use dashed symbols (boxes or ovals) to display information that has not been proven to be a fact (verified by two independent sources) and for questions.
You might also ask:
What evidence (broken parts, log books, strip chart recorder paper, computer printouts, medical records, video tapes, etc.) needs to be collected immediately and preserved? Is any evidence transitory or fragile so that special care is needed to preserve it? Decide what pieces of evidence need to be secured immediately. Make a list of items on your chart that need specific care so that evidence is preserved and then make sure that the preservation is accomplished.
In this example, you might want to get pictures of the scene before it is cleaned up and verify the lockout/tagout before anything is changed.
Once you have answered the immediate questions and ensured that any transitory evidence has been secured, you can start developing your investigation plan further. Look at your chart and consider:
- What are the legal, regulatory, and public relations implications of the incident?
- Should the investigation be performed under attorney-client privilege?
- Do you need a legal, regulatory, or public relations liaison as part of your team? Decide if you need to visit your corporate counsel.
- Are there any other special skills that you need on your investigation team to understand what happened or to collect evidence? Decide if you need to hire outside consultants to help with the investigation or evidence analysis.
- Does any part of the story NOT make sense?
- Is there conflicting information?
- What problems need further investigation?
- Did the people who observed or participated in the incident fill out an Initial Observation Form? The form is provided in the TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills book.
- Who knows what? Decide who needs to be interviewed and in what order. Develop your interview list and assign particular interviewers or interview teams.
- What are the key facts or times that need to be checked to verify the SnapCharT®?
- Do you have two sources of information to validate key parts of your chart? Decide what independent sources of information need to be developed to verify “facts” and confirm stories. This will help you turn dashed Events and Conditions into reliable information.
- What procedures and policies were (or should have been) used during the incident? Decide who will collect these BEFORE interviews are conducted. This will help your interviewers (or interview teams) develop their questions.
This is only a partial list of potential areas to be developed in the planning of an investigation. The Incident type and facts may suggest other areas that need to be considered when planning an accident investigation.
The more experience as an investigator you are, the better your plan will be. But the questions above should get you started.
Next, you need to decide how many and what type of investigation team members you need by answering these questions:
- How complex is the incident?
- How much information do you already have?
- How good do you think the information is?
- How much work will it be to verify the information you have and fill in missing information?
- How much of the investigation can be performed by others (regulators)?
- Will you have timely access to the information others are collecting?
- Can you rely on information collected by others?
- What is the quality of the investigation performed by others?
- What types of problems are there to investigate?
- Are there personnel injuries, environmental releases, operator errors, maintenance issues, contractor issues, or equipment damage? Decide what type of background the investigation team personnel need.
The answers to the previous questions can be added to your planning SnapCharT® in dashed Conditions or in a simple planning document to keep track of your evidence collection efforts. At a minimum, you will need an interview schedule and an evidence log.
Your SnapCharT® Diagram will become more complete as the investigation progresses. The first SnapCharT® should not be viewed as what happened. Rather, the first SnapCharT® should only be seen as a jumping-off point to start collecting factual information. Resist the urge to “verify” the first hypothesis that people have about what happened. Often, these initial stories are wrong (or at best, incomplete). The interviews and fact-finding you start in the next step of the TapRooT® 7-Step Major Investigation Process will lead you to facts that will supplant this initial SnapCharT®.
Other tools that can help you plan your investigation are some of the tools in the TapRooT® System. The two that are most often used are the Root Cause Tree® and the Equifactor® Troubleshooting Tables. These tools are taught in the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.
That’s a Good Start – Now Get Going!
If you read the planning section of the book, Using TapRooT® Root Cause Analysis for Major Investigations, you will find even more ideas for planning your investigation including optional techniques that you can use. But here is one thing not to forget…
A good plan today is better
than a perfect plan tomorrow.
General George S. Patton
Source for Investigation Planning Info
Where did this information come from? It is part of the book, Using TapRooT® Root Cause Analysis for Major Investigations (copyrighted and used here by permission of the authors).
This book is provided as part of the materials in the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. See the upcoming course schedule for public courses being held around the world here:
And don’t forget, the more practiced you have performing root cause analysis on precursor incidents, the better your major accident investigation will be.